Everybody poops — so, why is it so hard to talk about? — Chasing Life

[0:02] Hey there. Welcome to Chasing Life. Well, today on the podcast, we are going to tackle [0:07] a kind of awkward topic. It's something we all do, but we rarely ever discuss, at least not [0:14] in polite company, unless maybe you're the parent of a small child. I'm referring, of course, to [0:19] having a bowel movement, a BM, known as going number two, pooping. There's all these euphemisms, [0:27] both quaint and crude, to describe this. Even though it is universal, it is completely natural, [0:32] many of us get embarrassed simply talking about it openly. Sometimes we don't even discuss this [0:38] with our own doctors. But here's the thing. What happens in our gut has a profound impact [0:44] on our overall health, has an impact even on our brains. So today's guest is Dr. Tricia [0:50] Pasricha. She's a gastroenterologist and the director of the Institute for Gut-Brain Research [0:56] at Beth Israel Deaconess Medical Center in Boston. She's a really remarkable writer, [1:02] and she's come out with this new book called You've Been Pooping All Wrong, [1:06] in which she boldly goes where very few are willing to venture. Tricia's going to demystify [1:12] this vital but villainized bodily system. She's also going to share with us the secret [1:17] to achieving what she calls poop-phoria. And yes, that means what you think it means. [1:23] So stay with us today. Don't poop out. I'm Dr. Sanjay Gupta, and this is Chasing Life. [1:29] I got to say, I've really been looking forward to this, Dr. Pasricha. And I just want the audience [1:41] to know, first of all, that I am super proud of you. You were our intern here at CNN Medical [1:47] for, I don't know, ages ago now. And I think we all knew that you were going to go out and [1:53] do some amazing things, which you have done. You're obviously a doctor, but you've written [1:58] this amazing book, which I read, and I'm going to talk about that. And you're working for the [2:04] Washington Post. You're really getting your voice out there. So welcome to Chasing Life, [2:08] and know that we're all just so proud of you. [2:11] Oh my gosh, Dr. Gupta, that means so much. This is a huge full circle moment for me. So thank [2:16] you for having me on. [2:18] No, it's really our pleasure. We've all been looking forward to this. [2:22] You sent me the book, and I think I was texting you at the time. I was flying to the West Coast [2:29] from the East Coast, and I read the book in one sitting on my flight there. And I was totally [2:35] taken with it. I think I texted you right afterwards saying, I learned so much. And it [2:39] was funny. The book is called You've Been Pooping All Wrong. And part of me felt like I needed [2:44] to cover the title a little bit because I was one of them asking me. [2:47] Have you been? [2:50] Right. How did you come up with the title? [2:54] Yeah. The title is really a conversation starter or a conversation stopper, depending on the [3:01] situation. But it actually came from something that I heard myself saying in my mind all the [3:08] time when I was meeting patients. And then eventually I started saying it out loud. But I think that [3:14] people who came to my clinic when I was starting up fellowships, so this was about five years ago [3:19] when I finished GI fellowship and was practicing on my own, I began to realize that what I thought [3:27] was completely normal and normalized conversations about our bowel habits and pooping and how our [3:33] gut works, how the enteric nervous system works, these were not conversations other people had [3:37] grown up having. And I only had them because my dad was a gastroenterologist and still is a [3:42] gastroenterologist and loves what he does and was always getting into the weeds of these [3:47] conversations. So I thought it was very normal. I came to find out later the hard way that some [3:53] people find these conversations very embarrassing and they're not having these conversations all [3:57] the time. And patients would come in to me, you know, often they'd have one specific reason [4:02] they'd come. Like maybe they have abdominal pain, maybe they need a colonoscopy. But what they [4:06] really wanted to ask sometimes was, well, is this normal? Is my bowel movements normal? Like they [4:11] wouldn't even kind of know some of the basics. And then you'd kind of like open up the door, [4:16] you'd crack the door open to be like, well, what do we know about this? What do you, you know, like, [4:19] what do you think is normal? And just the floodgates would open about how little people understood [4:24] about their bodies. And sometimes I would find myself saying, wow, you've been doing this wrong your [4:28] whole life. Let's start over. Let's just like, you know, eliminate everything you thought you knew [4:32] about how you're supposed to do this and how your body works. Let's just start from scratch. And [4:36] from there, I decided I was going to write a book about it, partially because I think it helps spread [4:41] the word more easily. It's hard. I mean, we know it's hard to get a GI doctor's appointment. But also [4:47] for the fact that I think this topic has been stigmatized for so long, with that title, I really [4:53] wanted to just say it, say it up front, say it loudly, and hope to try to de-stigmatize something that [4:59] we're all worried about. 40% of Americans struggle with their bowel habits every day. That's a huge [5:05] number. And this is not people, these are not people who have a diagnosis per se. They don't [5:09] necessarily have a labeled condition, but their bowel habits just interfere with their daily lives. [5:14] I think we should change that because it doesn't have to be that way. [5:18] Right. I remember years ago, Oprah did a thing with Dr. Oz, and it was like one of the first things [5:24] Dr. Oz ever did, I think, for the show. And we were talking about it. I happened to be on set that day. [5:28] And it was about bowel habits. And it was really interesting to me because they got really [5:35] didactic. They showed what normal poop should look like. And what I can tell you is that while no one [5:42] in that audience probably would have asked about it, everyone was fascinated by it. And because it [5:48] affects all of us, but there's this taboo around it, this stigma around it. You didn't have it because [5:54] you grew up in a family of gastroenterologists. But that's not the case for most people. Why do [5:59] you think it is so taboo or stigmatized to talk about? And is that a U.S. thing or is that a [6:05] worldwide thing? Do different cultures sort of approach this differently? [6:09] You know, I have a lot of theories about why this is the case. One is that I think from our early days, [6:16] like probably the last time a lot of people had this conversation about pooping is when they [6:21] worked toddlers and when they were being potty trained. And even around that time, and I'm [6:26] actually like really deep in potty training my two-year-old right now. So I like understand this. [6:31] So it's close to my heart. But I think even around that time, a lot of parents treat going to the [6:37] bathroom as yucky. And they call poop yucky. And they kind of start to make you feel like this is [6:43] something that you need to have control over. It's embarrassing when you don't. And you need to [6:49] kind of distance yourself from it as soon as it's over. And I think it spreads from the idea that, [6:55] yes, you can spread diseases through poop and through not washing your hands. That was an old [7:00] fear that I think has lingered. But it's taken on this idea that it's disgusting. And by no means do [7:05] I think it's overly delightful by any means. But I certainly don't ever want my kids to feel like [7:11] that they should be embarrassed by what's going on and that we shouldn't have this conversation. [7:14] Once you bring it up, once you just open the door to it, everybody wants to talk about it. In fact, [7:20] everyone's relieved that someone's able to have this conversation and that they can get knowledge [7:25] about it. Because it's the thing that I have found, I mean, I know this from my patients and [7:30] from everyday experience that it's something that can make or break your day. You know, like being able [7:35] to eat what you like and then being able to comfortably get rid of it. That's something that people would [7:40] give up a lot in their own life to be able to get back. Yeah, I think there's no question. And I [7:45] think this is one of the few topics, I mean, joking aside, one of the few topics in medicine that is so [7:51] significant and so poorly discussed or inadequately discussed at the same time. Perhaps things like [7:58] addiction would sort of fall into that category. But this is something that is so basic to human [8:02] biology and yet so rarely discussed. So the book, you know, I think really does open the door to [8:11] this. And, you know, I think, like I said to you right away, I think this is going to be a really, [8:15] really important popular book because of that reason. You provide really sound medical guidance [8:21] here, which frankly is very reassuring, I think, for a lot of people. And I think that that's going to [8:27] be. But 40 percent is a big number, Tricia. You know, 40 percent of people have their daily lives [8:34] disrupted because of their bowels. 15 percent have irritable bowel syndrome. Yes. Have those numbers [8:41] gone up? And what do you think is going on here? Certainly those numbers changed a lot with the [8:46] pandemic. And every time there's a big infectious outbreak, about one in three, one to four people [8:53] do go on to develop irritable bowel syndrome. And so we certainly saw just a population-wide [8:59] surge of irritable bowel syndrome after COVID. But it's one of those things that you'll see if [9:04] there's a case of norovirus or if there's an outbreak of like everyone in your family gets [9:09] food poisoning. It's actually a good percentage of people who get irritable bowel syndrome. And it [9:13] may not be forever, but it may be something that lasts for months to years and people are living with. [9:18] So over time, they track the number of cases of irritable bowel syndrome went up. [9:22] The number, the 40 percent, has that changed over time? I think that my guess that that particular [9:28] number has probably stayed similar over time. I mean, it's a big number. And I sometimes see this [9:34] with my patients. A lot of people might think, oh, I'm not in that group. Like I think I'm doing just [9:40] fine. But sort of my litmus test for that is ask your partner, do your bowel habits disrupt your daily [9:47] life? And sometimes people are surprised because they're like, no, I'm not constipated. I have no [9:50] trouble. And their partners will be like, are you kidding me? You spend 45 minutes in the bathroom [9:55] every morning. We're like late to go out all the time. And sometimes you don't really realize how [10:00] disruptive your habits are until you move in with somebody or until you go to college and you see [10:05] what other people are doing or until your partner finally breaks and says, we have to talk about this. [10:10] But you might have normalized what you're doing for so long simply because you don't know [10:15] that it's actually not the average experience. You know, I read a stat that for younger people, [10:20] 80% for some of these younger people, 80% of their diet is basically processed foods. [10:25] Yeah. Are processed foods part of the culprit here? [10:30] Yeah, I've read similar stats. And that's changed certainly over time. And I think that's part of why [10:36] IBS, I think that section of the population has been growing and changing. It's not just the [10:41] infections. And they've done a few studies on this in large epidemiological studies where they have [10:49] linked ultra-processed foods with worsening symptoms in irritable bowel syndrome. A lot of what we [10:56] understand about ultra-processed foods and the gut in irritable bowel syndrome and pain comes from [11:01] translational or basic studies. And in those studies, we have certainly found that ultra-processed foods [11:06] decreases that mucus lining in our colon. That is so important because our colons are lined with [11:13] this layer of mucus that really protects us from the outside world. When these ultra-processed foods, [11:18] some of the additives and chemicals in them deplete that layer, not only does it change the bacteria [11:23] that are living there happily in that layer, now they can't do that, but it makes you more susceptible [11:29] to the outside world and the environment in which you're putting in there. And so we think that some [11:33] of those things do have to do with it. And of course, then there's this other very concerning [11:37] finding that I know you've reported on about ultra-processed foods and this link to colorectal [11:41] cancer. And we're certainly seeing a lot of early onset cases of colorectal cancer. Those have been [11:46] rising for now several decades. And that link is starting to become much more clear with ultra-processed [11:51] foods. We've been using two terms, irritable bowel syndrome and constipation. I think most people [11:57] understand what constipation is, although there may be a medical definition of it as well. But first of all, [12:02] with irritable bowel syndrome, what is it exactly? [12:06] Yeah, that is a huge, huge question. Irritable bowel syndrome is one of those syndromes that I think [12:11] when people hear that word, they think it's what we would call a diagnosis of exclusion. It's what you [12:17] give, it's the diagnosis you give somebody when you don't know what's going on, when all the tests [12:21] are normal. And in fact, we've, over the last two to three decades, really clarified what it is [12:28] that's happening. So on the surface of it, irritable bowel syndrome is this incredibly common [12:32] disorder where people have pain or discomfort associated with having a bowel movement. And [12:37] there's some people who have constipation. There's some people who have diarrhea. But in all cases of [12:42] irritable bowel syndrome, there's a lot of discomfort that goes into that. And that's something that they [12:46] live with for at least three months, often for several years. And the tricky thing about this is that [12:52] most of the tests that we do in a standard clinical environment are negative, meaning you could get a [12:58] colonoscopy, you'll get biopsies, they won't show any abnormality. You'll get blood work, those probably [13:03] won't show any abnormality. And sooner or later, your doctor will eventually say, well, okay, it's not [13:10] something that's causing inflammation, it's certainly, you know, nothing worrisome, we're going to call [13:15] this IBS. And what's actually happened is a change in the enteric nervous system. The enteric nervous [13:23] system is this network of nerves throughout the gut that is in close communication with your central [13:27] nervous system in your brain. And there are lots of different abnormalities in IBS. It's actually kind [13:33] of like a lot of diseases where there's not one singular abnormality. It's multiple different things [13:38] that happen. But one of the common themes is that the nerves in your gut become hypersensitive, [13:45] meaning it takes a lot less for them to react and trigger and send pain signals up to the brain. [13:51] The reason that we don't have a good test for that is that much of the enteric nervous system [13:56] lives in the deep muscle layers of the gut. You can't reach that with a surface level biopsy on a [14:01] colonoscopy. That would cause a hole in your colon. We certainly don't want to do that. But in research [14:07] studies, we know it's there. So sometimes even knowing, yes, there is, people are aware that [14:12] there is a true abnormality here can be really validating and reassuring to people. [14:18] What can our bowel habits tell us about our health? [14:22] Yeah, I think they can tell you a lot. And I sometimes think about this statistic that came [14:28] from the UK, but it really bothers me, which is that one in three people will avoid talking to [14:35] their doctor about their bowel habits because they're so embarrassed. And I always sort of anchor [14:40] with that statistic in mind because if you don't get in the habit of routinely looking, looking is [14:47] the first step, knowing what your normal is, knowing what your kind of fluctuations in your pattern could [14:53] be considered normal, you're not going to know when something is a little abnormal for you. There's a lot [14:59] that you can learn first just by looking and understanding what your pattern looks like. One, [15:03] the consistency tells you a lot. There's actually been very good data that shows that the consistency [15:09] of the stool, so meaning how soft and fluffy it is versus how hard or pebbly it is, that can give you [15:15] a good sense of how quickly that stool has moved through your body, how long it's been sitting in [15:20] your colon, because one of the colon's jobs is to suck water constantly out from what's inside back into [15:26] your bloodstream. So if it takes longer, more and more water is getting sucked, you know, and the stool [15:30] becomes drier. It can tell you about that. The color can give you a lot of information, and certainly [15:36] there's a very important point to be made that if somebody sees red, sees something that looks like [15:41] blood, haven't had beets, beets are a classic masquerader, but anything that looks like blood, [15:47] you shouldn't assume is hemorrhoids or shouldn't assume is no big deal until you have a doctor just [15:52] confirm and make sure about that. So anything that looks like red is concerning. And then [15:57] how you feel around the time. Are you feeling discomfort? Are you straining? Straining is a big [16:04] sign. People often talk about frequency as being the most important thing, and to me, that can [16:10] actually be the least important thing. How you feel, whether it was comfortable and effortless, [16:15] is the number one criteria for me about whether something is normal. If you go once a day, but you [16:21] strain for 20 minutes, and you strain your eyeballs out, I don't think that that's normal. But if someone's [16:26] going, you know, every other day, but it's completely effortless, I think that's totally [16:30] normal. So it really depends. But I think you have to ask yourself, how much time am I spending in the [16:36] bathroom to do this? And am I disrupting my own life? Am I disrupting other people's lives because [16:42] of this? More of my frank discussion with Dr. Trisha Pasricha right after the break. Welcome back to [16:54] Chasing Life and my conversation with Dr. Trisha Pasricha about a universal but taboo topic. Is there [17:04] an ideal way that or amount even people should be should be having bowel movements? I think a lot of [17:13] people think the answer to that is you should go once a day and you should go in the morning. And I [17:19] think that your body actually is physiologically primed to go in the morning. So it can be nice if you [17:24] can lean into that natural physiology. And the reason for that is that your colon is kind of like [17:30] the rest of you. It operates on this circadian rhythm more strongly than a lot of your other [17:35] organs. And so it goes into this really quiet, still state at night when you sleep, right? Like [17:40] your heart is still beating. It might be a little slower. Your colon's really not moving too much at [17:45] night. When you wake up, though, it buzzes with activity for the first one or two hours upon waking. [17:51] And your colon on its own is going to contract more strongly than it's going to do so for most of the [17:58] rest of the day. So if you can lean in and try to have a bowel movement during those first hours, [18:03] when your colon's doing the work for you, it means you have to do less work because you don't have to [18:08] strain as hard. And then often in the morning, people are having a cup of coffee, which can, [18:12] for one in three people, coffee triggers a bowel movement. It causes those contractions. [18:16] You might go for a walk in the morning. That's very common. I walk my dog. Exercise and just even [18:21] moving around gets things going. So you do a lot of things in the morning that come together. But [18:25] again, it's very common for people to experience another wave of just those natural contractions [18:31] in your colon anytime they eat. So just eating that mechanical distention of your stomach sends [18:37] this signal up to the brain in a reflex, and then it causes the colon to start to contract. It's why [18:41] people sometimes within minutes of eating sometimes feel like they have to go to the bathroom. And [18:47] it's not because that food suddenly made it all the way down to the colon. That's not the case. But [18:51] it's this reflex, and it's totally normal. And again, I just want to emphasize this point. [18:57] You have to sort of compare yourself to you, right? I think that's, again, one of the things I took away [19:04] from the book is that things might be very normal for you, might be very different for someone else. [19:10] But what you're really concerned about, Doctor, is when that individual has a change in bowel habits. [19:16] Like if they start, if they're going every couple of days, and now they're going three times a day, [19:21] or vice versa, that would be a concern. And why is that a concern? What do you think, [19:28] what are you worried about at that point, if someone has a change in bowel habits? [19:32] Well, I worry about two things. One is, I certainly worry if it comes to your attention, [19:37] because that change is now causing you problems. Like you now say, I have this urgency to go and [19:45] I'm struggling socially. I can't make it to the bathroom. This is, this is like bothering me. Or [19:49] suddenly I'm straining. This is like very uncomfortable. When you have symptoms, I'm always [19:55] concerned and I will always try to figure that out. But sometimes it doesn't quite reach that level, [20:00] even, of you saying this is overly bothersome. You might just say, I noticed that my, my stools are [20:06] suddenly really, really thin. That doesn't inherently bother me, but it's new. It's different. [20:11] It's weird. That bothers me because that's a change that's worth investigating why. Now, every time you [20:19] have a change in your bowel habits, it may not be something worrisome. What I'm worried about with [20:23] the change in the caliber and something becoming thin is that could there be a mass or something [20:27] squishing it that's causing it to be thin like that. But people are going to have daily fluctuations. [20:34] You, you, we've, we've talked about, you know, process and ultra processed foods being problematic. [20:40] To, to sort of flip the script on that, is there an ideal diet for colon health? [20:46] Yeah. They've done so many of these studies. Actually, a lot of them were done here by my [20:50] colleagues at the School of Public Health looking at the Nurses' Health Study, which a lot of people have [20:54] heard of trying to figure out what are the kinds of ways that we eat in America that are linked to [21:00] better health outcomes with our guts. And I think that at the end of the day, what we've learned from [21:05] a lot of these studies is that it doesn't have to be so prescriptive in terms of cutting out a lot of [21:13] different foods, but it seems that diets that most closely mirror something like the Mediterranean diet [21:19] seem to be beneficial, not just for your brain and for your heart, but really for your gut. What the [21:24] basic principles are that have been shown in the Mediterranean diet and other kind of anti-inflammatory [21:29] diets that benefit the gut are eating more fiber. Like you said, if I could do just one, two, and three [21:35] things, I would eat more fiber, eat more fiber, and eat more fiber. And for women, it's for under 50, [21:40] it's 25 grams per day. For men, it's 38 grams per day. If you were to just stop and count like one day, [21:47] a typical day in your life, how many grams of fiber are you actually getting? 95% of us are not [21:53] going to be getting enough. And that's the first place to start. And then it's thinking about, [21:58] okay, well, what are the ways to incorporate more whole grains? Yeah, I'm eating more vegetables, [22:03] but can I eat a diversity of vegetables and fruits and legumes? Legumes are really underappreciated. [22:09] And the fewer kind of inflammatory foods, which are the processed foods, the processed meats, [22:15] the better. It's not all or nothing. It's never going to be all or nothing. But if you can start [22:21] making small swaps, even if it's as little as a fiber supplement, that's better for your gut health. [22:26] And the reason that it's great for your gut is we talk so much about, in popular culture, [22:31] about probiotics and the microbiome. And the point that I want people to remember about the microbiome and [22:38] why these foods matter is that your microbes feed off of the things we cannot digest. And usually that is [22:44] fiber. It can be resistant starches and other things, but it's the fiber that makes their way [22:49] down to the colon. And how much fiber you're getting, the kinds of fiber you're getting it, [22:54] will change the species of the bacteria living there. And once they metabolize and they ferment [23:02] these different kinds of foods that you are choosing to give them, they produce new compounds [23:06] called postbiotics. The postbiotics is like the underappreciated part of the microbiome conversation [23:12] that I think is the most important part. Postbiotics are the compounds that the microbes produce. [23:17] They're new compounds. You're not making them. They're not technically your body. They're coming [23:21] from the bacteria, but you absorb them. They enter the bloodstream. And a lot of these postbiotics, [23:28] people have heard of short chain fatty acids. Butyrate is like a very commonly known one because [23:33] certain bacteria tend to produce it. They're anti-inflammatory. They're the reason [23:38] that we think your microbiome plays such a big role in dementia, in cardiovascular disease and [23:43] different kinds of cancers. It's these postbiotics that your bacteria are producing. And so ultimately [23:49] you can trace the pathway of those postbiotics back to what you're eating and what you're feeding [23:54] yourself. You do talk about poopphoria, which I think is another great term. What is poopphoria and how [24:02] do we get there? Yeah. Poophoria is a state of mind. It's a way of living that is somebody who actually [24:12] never thinks about their bowel movements. Poophoria is really where pooping is the least of your daily [24:17] concerns. And, you know, as simple as that sounds, it's quite profound for a lot of people. It means you [24:24] can eat the foods you enjoy, you get rid of them, and you're not tied physically or mentally to where [24:32] the bathroom is. Nobody is bothered by what you're doing. You're not bothered by what you're doing. [24:38] And it's also not the thing that keeps you from going out to brunch with your friends, from a nice [24:44] long hike with your dog, from traveling. All of these things get disrupted when you're not living with [24:51] puphoria. And frankly, that's so, so many of us. A lot of people, I was just talking about this [24:56] earlier today, people can't poop at work. And these are small, it feels like small things, but they [25:03] really can impact somebody's quality of life. And I, you know, as a gastroenterologist, I treat people [25:09] who have a whole range of things going on. Some people are going to need medications and more [25:14] specialized treatment. A huge majority of people just need a little bit more education about how their [25:21] bodies work and making small changes in their own lifestyle that can improve things so much more [25:27] than they even realized. It's a great book. Everyone, I hope, gets a chance to read this book. [25:33] I am curious, being a dad of girls who are not that much younger than you now, what did your dad say [25:39] when you read the book? Oh, he's the proudest dad in the world. He was so happy. He actually, I mean, [25:45] he was moved. He was moved to tears. It was like really meaningful, but it, he really did just have [25:51] such a big impact on who I became or the kind of doctor that I hope I still am today or I'm trying to [25:56] be. It would be no surprise to me if he was very proud of you. We all are. And I really do hope [26:03] everyone gets a chance to read the book. Thank you so much for being on the podcast and thank you for [26:08] sharing the book with the world. Thank you so much for having me. [26:14] That was gastroenterologist Dr. Tricia Pasricha. I should point out she gave one more tip at the [26:20] end of the podcast, which is stop taking your phone into the bathroom. You end up spending way [26:27] too much time there. Her new book is called You've Been Pooping All Wrong. It's out now. [26:33] Thanks for joining us on Chasing Life and we'll see you next week.