Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / GI Health For Women and Children plus Hormones, and the Gut-Brain Connection

Transcript

GI Health For Women and Children plus Hormones, and the Gut-Brain Connection · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

0:00
I'm Holly Wehmint, and this is Pediatrics Now.
0:04
Pediatrics Now is brought to you by the Department of Pediatrics at UT Health
0:08
San Antonio and University Health's new Women's and Children's Hospital.
0:14
I'm so thankful today we're recording this interview the week of Thanksgiving,
0:18
and I have here with me in the podcast studio Dr. Sarah Marucci.
0:24
She's an assistant clinical professor and the associate program director for
0:28
the GI Fellowship Program at UT Health San Antonio.
0:32
Dr. Marucci, thank you so much for being here in the podcast studio.
0:35
Thank you for having me. It's great to be here during Thanksgiving week. I'm thankful as well.
0:41
And I know you have a special interest in public health. You have your master's
0:45
degree along with your MD.
0:47
Part of my drive to be involved in medicine and eventually getting my MD was
0:53
my desire to care for the underserved and health disparities.
0:56
And And so that really drove me.
0:58
I was lucky to have a year after residency while my husband was finishing up
1:02
his residency to be able to pursue my master's of public health.
1:06
And so I was able to really kind of learn and dive deeper into health disparities
1:11
and what is the drivers for that, as well as be able to pursue my passion for global health, too.
1:17
And so I was able to spend some time in Honduras, especially during that year.
1:22
And it was really beneficial for my growth as a physician. My desire to serve
1:27
Hispanic population also helped me learn my Spanish a little better.
1:31
And so it's fun to be able to bring that passion here to UT.
1:36
What would you say is the number one misconception when it comes to our gut
1:42
health and especially the family doctors and the pediatricians listening who
1:46
have stressful jobs and are seeing 40 patients a day and probably don't have
1:50
time to worry about themselves a lot?
1:53
Yeah, no, I think it's very well known now that there is such a thing as a gut-brain axis.
2:00
And so we know that there is a connection between mental health as well as our
2:06
gastrointestinal health. And so I think it's important to know that that does exist.
2:10
And when we see patients that are or providers or just the layperson that has
2:16
increased anxiety or issues with depression, that often they do have concurrent
2:21
GI symptoms that, you know,
2:24
people will write off as, oh, just abdominal pain, like get over it.
2:28
But it can be very devastating to your quality of life and your ability to pursue
2:32
normal working hours, have a life, have a family.
2:35
And so, you know, you can have abdominal pain, diarrhea, constipation,
2:40
bloating, nausea, those types of symptoms that can be related to just what we
2:45
call an irritable bowel.
2:47
However, you know, those same symptoms can also be related to other conditions
2:51
that we, of course, like to treat.
2:53
Diagnose before we label you as having irritable bowel syndrome.
2:57
Things such as what we commonly see here in South Texas is like H.
3:03
Pylori infection, which is a bacteria that can cause various GI symptoms.
3:08
But we also want to make sure somebody doesn't have something like celiac disease,
3:11
doesn't have something called gastroparesis, which is kind of a, you know,
3:16
slow-moving stomach motility issues, as well as, you know, you drive into more
3:22
quote-unquote serious things, you know, making sure there's not ulcer disease,
3:26
there's not inflammatory bowel disease, there's not cancer.
3:31
And so, yes, sometimes, you know, just a stomach ache can be written off as,
3:37
oh, you're just anxious.
3:39
But I think it needs to be investigated, especially if it becomes more chronic,
3:42
and rule out the scary stuff before we say this is more commonly just an irritable bowel syndrome.
3:49
And so we have a special center with the name of what you're talking about, the access.
3:54
What is that called and what is that? So for the disorders of gut-brain interaction.
4:01
DGBI, we commonly see that in the literature.
4:05
But that's kind of the more formal term. You might have heard of functional
4:08
gastrointestinal disorders in the past. We like just kind of stay away from
4:12
the functional word because it puts a label on it.
4:16
But we know for sure, and I usually explain to patients, which can be sometimes
4:20
helpful for even us medical providers to understand, is that when nerves are
4:27
irritated in the brain, that same autonomic nervous system is what is driving the gut as well.
4:31
So irritated nerves in the brain can cause irritated nerves in the gut.
4:35
And so basically we become more hypersensitive to normal gut function,
4:40
whereas normal colonic motility, the normal peristalsis, could be seen as a spasm or severe pain.
4:47
And then it becomes more complicated, the disorders of gut-brain interactions.
4:52
We know that the gut microbiota plays a big role, which can affect the gut barrier
4:57
integrity, affect the immune system, can affect our digestion,
5:03
the underlying neuromotility.
5:07
And so it's a very kind of complex issue, but we know for a fact that this exists,
5:12
that patients and providers, we're not crazy when we say that we have a stomachache
5:16
when we're more anxious.
5:18
Or, you know, when you have large stressors in your life and you realize that
5:21
you're having a lot of diarrhea and are constantly running to the toilet.
5:25
We know that there is that connection and that's very important to address and
5:28
something that needs to be known that you're not crazy when you say you have
5:33
these symptoms. But then what do you do about it if you have those symptoms?
5:37
Yeah, yeah. So, you know, coming in to a GI doctor is important where we can
5:41
do further testing to rule out the quote-unquote more scary or serious things
5:45
that have other important treatments.
5:49
For example, celiac disease would be more a dietary type treatment,
5:52
and we can test for that with either a blood test or endoscopy.
5:56
And if you do have warning signs such as
5:59
You know, significant nausea, vomiting cannot keep anything down,
6:02
or you have significant weight loss unintentionally.
6:06
If you have any GI bleeding, whether that be melana, so kind of black tarry
6:11
stool, or if you have bright red blood per rectum, those types of things need
6:15
to be investigated endoscopically to rule out more significant diseases.
6:20
Once that's done and we don't think that there's anything else going on,
6:24
other lab tests look okay, we rule out thyroid disease because that can cause some GI symptoms.
6:31
We rule out significant anemia, which we could see with GI bleeding or other
6:36
autoimmune conditions.
6:37
Then we say, okay, this patient probably has irritable bowel syndrome.
6:41
Then typically we're going to start with what we call more just kind of conservative supportive care.
6:46
And that would be things like if somebody has a more predominant diarrhea component
6:50
to their abdominal pain, then we might focus on adding more fiber to the diet.
6:57
Using over-the-counter kind of Imodium, those types of things can be very effective,
7:02
as well as dietary modifications.
7:05
The low FODMAP diet is often effective.
7:09
People might have heard of that, seen on Instagram, seen on TikTok,
7:11
you know, these types of things.
7:12
It's a very complex list of foods, but basically FODMAPs are naturally found carbohydrates in food.
7:20
And it's not that these foods are necessarily unhealthy.
7:22
They just have, when they're naturally broken down within our gut, they produce more gas.
7:28
It can cause various different GI symptoms, nausea, bloating,
7:33
change in the caliber of your stool.
7:36
And so avoiding those foods with higher amounts of those carbohydrates can be
7:41
a very essential part of the treatment for irritable bowel syndrome.
7:45
And in the FODMAP, it'll show what to try to avoid and also what is good to eat. Exactly, exactly.
7:53
So foods with high FODMAP, so high, it's fructose, oligosaccharides,
7:58
disaccharides, monosaccharides, and polysaccharides, basically the types of
8:01
normal carbohydrates that are found in foods. But those foods that have high
8:05
levels, we like to recommend to avoid.
8:08
So those are foods such as beans.
8:12
Beans are so good for us. Exactly. And that's the tricky part because,
8:15
hey, we're here recommending fiber.
8:18
But then we're saying, don't eat your beans. So that's why it's really important
8:22
to meet with a GI doctor and oftentimes a nutritionist, hopefully associated
8:27
with the GI clinic, that can really kind of dive down into the nitty gritty of what you can eat.
8:32
Because often it is the food. It's not the food might be contributing to the
8:37
problem. It really is the food. Yeah, yeah.
8:40
And it's such an important piece. You know, for example, a lot of,
8:43
you know, fruits and vegetables that are very healthy and that we're recommending
8:47
for patients to eat for their general gut health, things like mangoes or apples, tomatoes,
8:54
broccoli, those types of foods are very high FODMAP. It can cause a lot of GI symptoms.
9:00
So it's really important to have those discussions early on and for the patient
9:06
to understand that the diet does play such a big role in their GI symptoms.
9:11
So then they become more comfortable with being aware of what they're eating,
9:15
what they're putting into their body, and comfortable with the idea that sometimes
9:17
it's not just a medicine that's going to treat me, that I have to make these
9:21
changes in my daily life.
9:24
Before we talk more about women's gut health and prevention and what to do,
9:29
we're seeing an uptick, as we all know, in cancers in younger people.
9:35
And for our pediatric practitioner listeners, what's important when it comes
9:40
to kids and adolescents and early warning signs for a GI red flag?
9:46
Definitely. So it's very true. We're seeing colorectal cancer,
9:50
gastric cancers pop up much earlier. And it's scary.
9:54
It's scary for all of us. Even I'm relatively new as a GI faculty here,
10:00
but even over the course of my short-lived career, like I've seen earlier and earlier cancers pop up.
10:07
You've been doing this for about four years? About four years,
10:09
correct, since fellowship.
10:11
And so we, as GI physicians, have honestly taken complaints more seriously, too.
10:20
So especially in the younger population, somebody, you know,
10:23
a young female in her 20s who says that she has rectal bleeding,
10:28
maybe just had a baby, which can increase your risk of having hemorrhoids,
10:32
we'll say, oh, you know, it's probably just hemorrhoids.
10:35
Avoid constipation, increase your fiber intake, avoid straining on the toilet.
10:41
But nowadays, with our concern for earlier colon cancer, we're saying we got
10:46
to get that colonoscopy done.
10:48
We need to rule out any sort of advanced polyp coming up at an early stage or cancer.
10:55
So it is very important for us to hear that. I encourage all,
11:00
you know, if you are seeing any rectal bleeding, to get evaluated.
11:03
It's better safe than sorry to get your colonoscopy earlier rather than later.
11:08
Any other red flags, like if it's the worst stomach ache of a child's life?
11:13
You know, pediatricians see this a lot, so they know that could be a number
11:17
of things, right? Right.
11:18
And once again, as an adult GI doctor, I'm not typically taking care of the
11:22
PEDS population, but severe abdominal pain, I mean, it definitely should be
11:26
evaluated and at least have, you know, try to get as good of a history as you can with the patient.
11:33
And if there's any other associated symptoms with that, if it's,
11:37
you know, that they are having nausea, vomiting, not been eating,
11:40
have had significant weight loss, those symptoms are going to be concerning
11:44
and need to get evaluated right away.
11:47
I think something that we see a lot, too, is, you know, it can be complicated
11:53
with a lot of the diets and trends out there with people, you know, trying to lose weight.
12:00
And they think that they've been changing up their diet and that's contributing to weight loss.
12:04
But really kind of getting into the depths of, OK, really, how much weight have
12:08
you lost over the course of the last six months? How much are you really trying to lose weight?
12:12
Because that often is a significant red flag sign for us.
12:16
So weight loss, unintended weight loss, rectal bleeding, any other red flags
12:22
you want to mention? Yeah, I think...
12:25
You know, specifically for colon cancer, if the patient has had labs done as
12:30
well and there is evidence of iron deficiency anemia,
12:34
that is typically we're going to be more concerned about that in the elderly
12:39
population for underlying malignancy.
12:41
But even in a young patient or young provider, I mean, seeing iron deficiency
12:46
anemia should be evaluated with females in particular, especially when they're
12:52
in with still having their menstruation.
12:55
Typically, that's going to be the reason for iron deficiency anemia.
12:59
So understanding their cycle, how much they bleed is very important.
13:05
But then further evaluation, ruling out celiac disease, ruling out H.
13:10
Pylori and bacterial infection are kind of the next two options.
13:14
And then if those aren't positive, they're still anemic, they're not really
13:19
bleeding much in their menstrual cycle, then doing endoscopy,
13:23
making sure we're ruling out any sort of underlying malignancy or other GI bleeding
13:28
sources is very important, even at a young age.
13:31
And is H. pylori more common in people who bite their nails?
13:35
Is that a good reason to try to stop biting your nails? Or have you heard anything about that?
13:41
So typically H. pylori, it is a bacteria that is transmitted,
13:45
basically it kind of lives in the soil, transmitted through being a kid,
13:51
playing in the dirt, not washing our hands. And then it lives in us for our life.
13:55
But then because we have it, we can transmit it to other people in our household.
14:00
And so, yes, if you're biting your nails a lot and your son has H.
14:04
Pylori infection, that's something to be worried about. Granted,
14:07
a lot of times we don't know.
14:09
And so I will say, I mean, just hand hygiene in general in the household is
14:13
important and encouraging kids to do the same.
14:16
Teaching those practices early on is important, but I think it's,
14:20
especially here in the South Texas area.
14:23
H. pylori is extremely, extremely common and over 50%, especially if the Hispanic
14:29
population is going to have it.
14:31
And so that's why we are, and I can't speak for GI doctors elsewhere,
14:37
but here we're pretty quick to do upper endoscopies or at least stool tests
14:44
or breath tests to check for H. pylori infection.
14:46
If someone has symptoms? If someone has symptoms such as nausea or bloating,
14:50
some kind of vague GI symptoms, because we just don't know.
14:54
And H. pylori is something that is prevalent, something that can cause longstanding
15:00
issues, ulcer disease, as well as gastric cancer. And it's something that we can treat and cure.
15:05
So once again, kind of better safe than sorry.
15:08
Treat and then we can test and then we can treat. With antibiotics?
15:11
Yes. Yeah, we treat with a course of antibiotics for 14 days.
15:16
It's a challenging course of antibiotics to take. It's lots of pills.
15:20
Which antibiotics? For two weeks. It kind of depends. There's different regimens.
15:24
A lot of them can contain amoxicillin in them, but also tetracyclines and in
15:31
combination with a proton pump inhibitor.
15:34
So acid suppression is really important.
15:37
But those antibiotics themselves can cause GI symptoms. And so it's very important
15:42
just to have conversations with patients to let them know,
15:45
what to be prepared for, but know that treating this infection is more important
15:49
because we can cure it and reduce your risk of having complications down the road.
15:54
Does it lie dormant and then you can get symptoms later, or would you get the
15:58
symptoms right when you get it? Very much so.
16:01
Most people walking around probably have no idea that they have it and don't
16:05
really have much GI symptoms.
16:06
And oftentimes we're doing endoscopies on patients for other reasons,
16:11
and their stomach looks a little funky, and so we biopsy it,
16:15
and they happen to have H. pylori.
16:17
So it's definitely a more silent disease, but it's important to note that it
16:21
can cause a multitude of different GI symptoms.
16:25
And so it is some some recommendations have even said, like,
16:29
if a family member in your household has H.
16:32
Pylori for you to get checked as well, just because we do know that it does
16:36
is transmitted throughout the household and is something that we can treat.
16:40
Do you want to say anything about gluten?
16:43
I know like we probably all have friends who they will not eat any gluten.
16:49
They don't have celiac, but that for health reasons, like I have a friend who's
16:54
doing it because she feels like it'll help her not to have have to take thyroid
16:58
medication because their thyroid numbers aren't looking good.
17:01
Like what are gluten free? What's your advice? Yeah.
17:05
So I have a particular interest in this because I myself have celiac disease.
17:10
I was diagnosed when I was a kid. I'm in about sixth grade because I was having,
17:15
unintentional weight loss and just was malabsorbing, just looked sickly.
17:21
And so that was evaluated and ended up having endoscopy biopsies proven to have celiac disease.
17:27
So I've been on a gluten-free diet for years and years and years.
17:30
And thank goodness it was caught early. Yes.
17:32
Yes. Thank goodness. And I was pretty sick for a while. But my mom is a pediatrician.
17:36
And back then, celiac disease was not on the radar.
17:40
And she took it very personally that she could not figure out what's going on with me.
17:45
But times have changed. And I think, you know, we do think about celiac disease
17:49
much, much more often now in the pediatric and adult world.
17:54
But, you know, gluten-free is known to be the only treatment that we have for celiac disease.
18:00
And that is because gluten causes antibodies to form in the body that can attack our small bowel.
18:06
However, we also know that gluten in patients that don't have those underlying
18:10
antibodies can also irritate the gut lining,
18:14
cause some dysbiosis within the gut microbiota, going to affect the integrity
18:20
of the gut wall and can cause kind of that irritable bowel type syndrome.
18:25
So if you don't have celiac at all, it still can't. Exactly.
18:28
And gluten itself, gluten-containing foods, so that's kind of wheat,
18:32
barley, rye-based products, those are high FODMAP.
18:38
So if you look at a list of high FODMAP foods, gluten-containing products are
18:42
going to be all over that.
18:43
So we know that avoidance can help a lot of GI symptoms.
18:48
It can be a little bit controversial on, you know, some of the lingo related
18:53
to, you know, if this is celiac versus non-celiac gluten sensitivity.
18:59
And just patients that don't even have that labeled would just want to avoid gluten.
19:03
But I think in general, if patients feel a lot better, if they avoid gluten
19:08
and it's not affecting their quality of life or their social situation,
19:13
their family life, then I think that that's okay.
19:16
But avoiding gluten completely for other health reasons, like,
19:21
you know, treating the other conditions like thyroid or cancers or other things
19:27
like that, there's not a lot of data out there for that. So I can't,
19:32
encourage that as much as if it just if you are feeling better avoiding the gluten, then go for it.
19:40
But it's hard. It's a it's a restrictive diet.
19:43
And so it really you really have to find the benefit in your symptoms if you
19:47
don't have celiac disease in order to really argue to stay off it completely.
19:51
My daughter's best friend, her dad was eventually diagnosed with celiac disease,
19:57
But it wasn't until he was an adult.
19:59
And all of his siblings are his brothers are very tall and he's not at all tall.
20:04
And he was very sick as a child. And I just could not find out what was wrong.
20:08
And then so they got their kids tested. And so now their daughter,
20:13
like she's growing and thriving.
20:15
And it has very with the diet. It makes a huge difference.
20:19
Yes. Yes. But it's challenging. It's a challenge. Avoiding gluten and as well
20:23
as, you know. Seems like it's in everything.
20:24
It is. I mean, it isn't a lot. And luckily nowadays, it's gluten-free foods
20:29
are everywhere and most people know what it means, but there's still risks of
20:34
contamination and people that, you know,
20:39
don't take it as seriously as they need to.
20:43
And so they, you know, sometimes I'll go to a restaurant and be like, is this gluten-free?
20:47
And they're like, oh, yeah, but then I've realized that they've used flour in
20:50
the sauce or something like that. Because you feel sick. Because it's, yeah. Yeah.
20:54
So it, you know, it's tricky as well as, you know, a lot of the FODMAP diet,
21:00
kind of going back to that, you know, we say, you know, don't eat a high FODMAP
21:04
diet and they try to avoid it.
21:06
But then the soup that they make also has, you know, the base is always onions and garlic.
21:11
And those are high FODMAP foods. So even though if they're avoiding the beans
21:14
or avoiding the, you know, culprit vegetables and fruits and gluten pasta in
21:20
the soup, if it's still a base of onion and garlic,
21:24
you know, that still could be causing some symptoms. So it's tough.
21:27
It's tough. And that's why it really is important to have repeated conversations,
21:32
food diaries, really kind of understanding what you're eating and being aware
21:35
of that is important from both the patient and provider perspective.
21:38
And it's great we're talking about this Thanksgiving week. Yes, exactly.
21:42
And so, but bottom line with FODMAP, who would you recommend?
21:45
Who is the, like that, who should be looking at the FODMAP diet?
21:49
Who can that help? Exactly. I think we...
21:52
In particular, people that have been diagnosed with irritable bowel syndrome,
21:57
FODMAP, dietary modification can be very beneficial.
22:00
But even people that haven't necessarily gotten the label of irritable bowel
22:04
syndrome, having the knowledge that those foods just in their natural process
22:09
when they're broken down by our bodies produce more gas, that we could all be
22:13
somewhat sensitive to it.
22:15
You know, I think I know for myself when I eat more broccoli,
22:18
like I'm going to be a little bit more bloated.
22:20
Is it worth it, though? But to me, it's worth it. To me, it's worth it.
22:23
And I get my fiber in, you know.
22:25
So but just having that knowledge, I think, is really important for patients
22:29
and just their their mindset to be just it kind of switches it saying,
22:33
you know, OK, I'm not there's nothing necessarily wrong in my body,
22:38
something that's going to kill me.
22:39
It's not it is serious because it's affecting your
22:42
quality of life and your symptoms but it's not something that is
22:46
going to need you know further procedures or significant medications
22:50
it's more of a mindset of okay i gotta switch the
22:53
way that i'm living and i'm eating in order to best treat this sarah i think
22:59
it's so interesting what's being discovered about the gut brain connection i
23:03
i worked for about a year for the nurture science program at columbia university
23:07
and where it was the research finding the healing power of nurture.
23:12
Particularly between parent and child, mother and child.
23:15
And the NICU at the new Women's and Children's Hospital is the second NICU in
23:22
the country to be empowering the healing power of nurture and the principles
23:26
of nurture science for that gut-brain connection. Mm-hmm.
23:30
And how crucial that is. And then like, we all know if something,
23:33
if our child is going through something hard, or if we're going through heartbreak
23:37
or something where our stomachs can hurt too, it's real.
23:41
It is. It is very real. And I think that's one thing that I'm passionate about
23:45
with my patients. And some GI providers kind of roll their eyes when it's like,
23:49
oh, another irritable bowel syndrome patient or something like that.
23:52
But it's so true because it really does affect your quality of life.
23:55
And having those conversations and understanding the connection is so essential.
24:00
And understanding that we need to, you know, be able to support ourselves and
24:05
our mental health as well as have a support system around us in order for our
24:09
gut health to be, you know, where we need it to be.
24:13
Sarah, what unique issues do you see in female gastrointestinal health?
24:18
Do you want to talk about hormonal differences, puberty, menstruation, pregnancy, menopause?
24:24
Yeah, for sure. So, I mean, I think in general, females, we have to be aware
24:29
that hormones do play a role.
24:31
And estrogen is known to have kind of a multitude of effects on the gastrointestinal
24:37
tract, especially kind of colonic motility.
24:40
It's a smooth muscle relaxer, so it can also potentially cause more acid-type
24:48
reflux symptoms, constipation.
24:51
Some people have more kind of urgency to use the bathroom.
24:55
There's a lot of different things that estrogen itself can cause.
24:58
It also can affect the gut integrity, the gut barrier integrity.
25:03
So sometimes in menopause, when you have lower levels of estrogen,
25:06
you're more susceptible to having irritable bowel syndrome develop.
25:09
You don't have that same kind of immune regulation, gut protection.
25:15
So we know that estrogen does play a role. And for that, we do see,
25:18
you know, commonly a lot more women with irritable bowel syndrome.
25:22
It's not only estrogen related, but it's something important for us to be aware of.
25:29
So could hormone replacement therapy help with that? So potentially,
25:32
you know, honestly, I don't know.
25:34
I'm sure there's probably some literature out there on that.
25:38
But that's an interesting thought.
25:40
And I know that I have had, it's important to know, kind of bringing it back
25:44
to the kind of puberty menstruation, that a lot of GI symptoms can be more severe during a cycle.
25:51
And that is potentially because of the fluctuations in hormonal levels.
25:56
And so I did have a patient who was put on oral contraceptives and her IBS,
26:04
her irritable bowel syndrome symptoms, have improved dramatically.
26:07
So I do think it's something to consider and think about and just understand
26:12
that connection between the hormonal cycles as well as GI symptoms and be aware
26:19
and question your patients about that and the cyclical nature of their symptoms.
26:24
And if it gets severe, see a GI doctor.
26:27
Yeah, yeah. And then also that kind of plays into being aware that gynecology
26:31
can help a lot in these situations because women,
26:34
we are, you know, at risk for having issues with our female parts that can cause,
26:40
quote unquote, abdominal pain.
26:42
Severe things you think of like torsion, ovarian torsion or ovarian cysts that might burst.
26:47
Those that's relatively rare. but things like fibroids, endometriosis,
26:53
it can cause a lot of abdominal pain.
26:55
And so often in my younger female patients,
26:58
I'll make sure that they have some sort of gynecological follow-up or imaging
27:03
like a transvaginal ultrasound to investigate that if they are coming in with
27:07
those symptoms and especially if there is a cyclical nature to them with their menstrual cycle.
27:12
Do you want to talk briefly about how the importance of getting a screening
27:16
colonoscopy and you see those commercials for where you can like send in a stool
27:21
sample like is that are those recommended if it says.
27:26
It can detect a certain amount of precancerous. I mean, is any of that real or what is your advice?
27:33
So we, of course, I always recommend starting screening for colonoscopy,
27:38
ideally if you're average risk, meaning you don't have family history of colon
27:42
cancer or you don't have underlying inflammatory bowel disease,
27:47
that you get a colonoscopy starting at age 45.
27:51
However, colonoscopy is not the only option that we have for screening.
27:56
For colon cancer. We also have non-invasive testing that are stool-based to
28:01
check for underlying DNA markers, as well as kind of like microscopic heme,
28:07
that can be present in the setting of advanced polyps or colon cancer.
28:13
So if you're average risk and you don't want to get a colonoscopy,
28:17
then going forward and getting a non-invasive test is recommended.
28:21
And what does that look like? So it would be include a fecal immunohistochemical
28:26
test or FIT test, which is a yearly non-invasive stool test that you kind of
28:32
smear a little stool sample,
28:34
send it in, and they look for the underlying markers.
28:37
You do that through your GI doctor? You can do that through primary care doctor,
28:42
through GI doctor, but generally we see it more through just the primary care.
28:46
Then there's also the ColoGuard test, which is a little bit more advanced than the FIT.
28:51
It's having more DNA markers included in that.
28:54
So it's typically more expensive, not always covered by insurance.
28:57
And so it can be a little bit more challenging to obtain.
29:01
But it is very effective and you only need it every three years.
29:05
So those are important. But it's important to note that, okay,
29:08
yes, this is a non-invasive test.
29:10
But if that test is positive, then the next step is doing a colonoscopy.
29:15
And someone who's considered average risk where this could be a good option would be,
29:20
Yes. So average risk, no history of family, no family history of colon cancer
29:25
or underlying kind of genetic syndromes that might put you at higher risk for colon cancer.
29:32
Things like Lynch syndrome or familial adenominus polyposis syndrome,
29:36
which we don't need to get into, but those that put you at high risk or having
29:40
underlying inflammatory bowel disease as well.
29:42
And if there's any type of family history, say a grandparent who got colon cancer
29:47
in her 80s, Is that considered a strong family history?
29:51
So a strong family history, a very high-risk strong family history would be
29:56
a first-degree relative, so sibling,
29:58
parent, that was diagnosed with colon cancer at 60 years or younger.
30:02
So that would be a pretty significant family history. However,
30:06
we would recommend that anybody with a family history of colon cancer start
30:11
getting a colonoscopy at age 40, so five years earlier than our general population.
30:18
However, if you have a strong family history of colon cancer,
30:22
then we would recommend doing it every five years from there rather than the
30:28
normal 10-year if the colonoscopy is normal.
30:31
Sarah, what else would you like to let us know about for the female pediatrician
30:37
listeners and our panelists?
30:39
Male pediatrician listeners who have women in their lives, what would you or
30:43
a woman in their life, what do you want us to know that we haven't talked about?
30:48
One thing I think is really important is the female pelvic floor.
30:54
And that is an important part of our evaluation in patients,
30:59
especially if they have chronic constipation, as well as pain,
31:03
kind of more chronic pelvic pain.
31:06
We know for a fact that chronic constipation, especially if it's not improving
31:11
with fiber or laxatives or even prescribed medications that we can give as GI providers,
31:19
that there's often a component of pelvic floor dysfunction that's contributing.
31:23
And females are at higher risk for this, largely in the setting of if there's
31:27
childbirth, especially vaginal deliveries.
31:29
But just in general, females are going to be higher risk. And so pelvic floor
31:33
dysfunction is basically when the pelvic floor muscles are not working in coordination.
31:37
And so they also can be weaker or less sensitive.
31:40
And so that puts you at higher risk for constipation, but also fecal incontinence,
31:46
those types of things. And so that's a really important factor to not ignore
31:50
because medications are not going to treat that.
31:53
And pelvic floor physical therapy is actually the way to go for that.
31:58
And so that's when we also are going to be working with other colleagues.
32:02
It's interdisciplinary.
32:03
It's not just in GI, but we have to work with physical therapy for that as well
32:08
as sometimes gynecology too. If there is some sort of anatomical issue,
32:11
sometimes after childbirth, you might have vaginal prolapse,
32:15
rectal prolapse that might need more surgical evaluation.
32:19
That's great advice. Before we get into prevention, is there anything else you want to mention?
32:26
I'd love to talk about lifestyle. As a GI doctor, and you know the inside scoop,
32:32
what do you do to keep your gut healthy, and what's important for all of us?
32:38
Yeah, no, I think for all of us, maintaining a healthy lifestyle is essential to healthy gut.
32:48
So starting practices early, encouraging, you know, your pediatric patients
32:53
up to yourself and your significant others to kind of adapt a healthy lifestyle.
32:58
By that, I mean making sure that you're eating a healthy, balanced diet.
33:03
Lots of fiber just in your general intake. Fruits, vegetables.
33:08
Legumes, and kind of whole grain type foods are going to be your best bets.
33:14
And so establishing that lifestyle early on is very important.
33:20
And then hydration is really important too. I think a lot of constipation type
33:26
symptoms is related to people just not drinking any water, turning to sodas or these, you know,
33:32
Celsius and energy drinks and that sort of thing where we really just need people to drink water.
33:37
And that can be very helpful. Exercise is also really important to not only
33:41
helping kind of stimulate some colonic motility, intestinal motility,
33:45
but it's also good for just the gut microbiota and our general health as well. Our mental health too.
33:55
As we mentioned, the gut-brain axis is real.
33:59
So all those are really important. And I think also just being aware of our
34:03
bodies, knowing when things feel off and getting that evaluated sooner rather than later.
34:08
And as a GI doctor, I feel comfortable saying this, but looking at your poop.
34:12
Making sure you don't have blood in your stool, making sure that the consistency
34:16
of your stool seems okay to you and seems regular.
34:20
And if there's a change, then notifying your primary care provider about that
34:25
who could then potentially get you into the GI. A major change or a slight change?
34:30
Let's talk about poop. Yeah, yeah, why not? You know, it's one of my favorite things.
34:35
I think, you know, it's important for everybody to know that everybody's different.
34:40
And normal can be somebody's not normal.
34:44
So, for example, people who, it's normal to have a bowel movement,
34:50
for some people, three times a day.
34:52
And that's their normal. Whereas somebody who also could have a bowel movement
34:57
every three days, and that's their normal.
34:59
So it's important to establish a baseline when talking to patients about their bowel habits.
35:05
So then when there has been a change, you understand what the change is.
35:09
Because somebody's normal of having three bowel movements a day to then going
35:13
to only having a bowel movement every three days could be a drastic change.
35:16
And that's a new symptom, a new constipation that potentially needs to be evaluated.
35:21
Are we still doing stool transplants for C. diff?
35:25
Good question. Unfortunately, no.
35:29
We could do it kind of in the more kind of scientific lab, but unfortunately,
35:35
the open biome, which was the stool bank that we would use for those cases, has closed.
35:41
And so, yes, we know for a fact that that is a great treatment for C. diff. It's amazing.
35:47
And especially in bad cases, you know, and patients extremely sick in the ICU
35:53
to patients that have had refractory or recurrent episodes.
35:58
We know that fecal microbiota transplant is wonderful, but now it's just not
36:03
available. Not available. Is it being done elsewhere?
36:06
Just not here or just not at all? I don't, you know, honestly,
36:08
I don't know outside of the U.S.
36:10
What is, but here in the U.S., we just don't have access to a stool bank.
36:14
Is that because of funding or what?
36:16
Honestly, I don't know the story behind it, but yeah, it's really,
36:20
it happened over this past year.
36:21
So it's very challenging for us because we don't have that option.
36:26
Yeah. But, I mean, you could potentially make your own stool transplant.
36:30
And, yeah. If you're close to someone, you feel comfortable asking.
36:34
One of my colleagues, that's how he trained. He would, you know,
36:37
family members of patients that were sick would donate their stool and they'd
36:41
dilute it, mix it up, and then put it in a syringe and deliver it via colonoscopy.
36:47
So just bring it, oh, have a colonoscopy and have the family member bringing it. Yeah.
36:51
So it's possible. It's not really done widely, but it is something that—,
36:58
you could do. But unfortunately, we don't have that access to the fecal microbiota
37:04
transplants like we used to,
37:05
which is a shame too, because there's so much coming out about the gut microbiota
37:10
and how kind of reestablishing a normal gut environment in the intestines can
37:15
be beneficial potentially for preventing inflammatory bowel disease and cancer as well.
37:21
So there's a lot out there. And so hopefully, I don't think this is forever.
37:26
Hopefully it'll come back. I think it'll come back.
37:29
Sarah, for our doctor listeners, anything else you want to say about poop,
37:33
about our gut, anything else?
37:36
I mean, I could talk about poop all day long, right?
37:40
No, I think one thing that, especially with females and gut health,
37:47
is that it's really important to sit down and address symptoms with patients.
37:52
Because so often it's just written off as you're crazy or you're just stressed out.
37:59
And yes, that could be the case that they also have some underlying anxiety
38:03
or depression, which needs to be evaluated and taken care of.
38:09
But we know for a fact that that can really disrupt our intestines,
38:14
our gut microbiota, our intestinal motility. We know that for a fact.
38:19
And so I think really addressing that and making sure that patients feel heard
38:24
and feel seen within the GI realm as well.
38:28
Not just the mental realm, but within the GI realm, I think is really important.
38:32
And there's the good stress and there's bad stress.
38:36
Yes, yes. Good stress helps us to do the talk, to pass the test.
38:40
Right, exactly. With flying colors.
38:42
Yes, yes, exactly. But that can also cause GI symptoms, you know.
38:46
My sister, I know, would sometimes have horrible stomach aches and have to throw
38:51
up before her speeches and that kind of thing.
38:53
So we know that there's that connection, good or bad.
38:57
And just either way, go see a GI doctor.
39:00
Yeah, yeah. And I mean, these conversations can also take place in just the
39:05
pediatric office, in the internal medicine office.
39:08
But I think for symptoms that aren't improved or really affecting quality of
39:12
life, then seeing a GI provider that just has that armamentarium of different
39:17
treatments and kind of the hierarchy of treatments, I think is important.
39:21
And last question about colonoscopies. If someone has a family history and then
39:26
they don't want the invasive test, if they got the Cologuard or the other test,
39:30
could that show if there was a red flag to then get the colonoscopy or it could be missed?
39:35
It could be missed. And so that's why we recommend that people with a significant
39:39
family history that have that just genetic predisposition that they go ahead and get a colonoscopy.
39:44
Because those non-invasive tests, yes, they're good.
39:48
They've gotten better, but they're not perfect. And they could miss things.
39:50
And the neat thing about a colonoscopy is that we can catch things early.
39:54
And so, yeah, that patient that has a family history, they might not have cancer
39:58
at 40, but they might have a significant polyp burden that we can take care
40:02
of and help prevent cancer down the road.
40:05
And the anesthesia has gotten better with propofol, and I've heard the PrEP has gotten better.
40:11
But that's not saying a lot. I don't know. That's still debatable.
40:14
I feel like that's one thing that we have a long road to really solve. Even with soup prep?
40:20
Is that what it's called? Yeah. It's still just...
40:23
Doesn't taste great. It's still a large volume that you got to get down,
40:27
even though it's, you know, there's pill based and smaller volume preps,
40:31
but then they still require you to drink a ton of water with that.
40:34
And so just the overall volume intake is a lot and hard to handle for a lot
40:38
of people. But it's important. Yes.
40:41
And Sarah, I like to promote on Pediatrics now having a life outside of medicine.
40:46
I know you love to read, listen to audiobooks.
40:51
What are you listening to now that you'd like to recommend? Yes.
40:54
So I love World War II, especially female-based World War II historical fiction.
41:02
I just finished an audiobook called The Historians, which is a really interesting
41:07
take on Sweden during World War II, which you don't hear a lot about.
41:11
So that was very good. And then I'm also finishing up The Thursday Murder Club,
41:15
which is British old people writing.
41:19
Hanging out in nursing homes, solving mysteries, which is one of my guilty pleasures.
41:23
And what got you interested in World War II historical fiction?
41:28
I've always just loved history. And I was almost a history major in college,
41:32
but I didn't want to write a thesis. And so I just stuck with biology and took
41:37
a lot of history classes.
41:39
But so I've always just loved that. I've especially just loved wartime history.
41:43
And then growing up, my dad was really loved history, too, and had us reading
41:48
about the wars and stories and visiting battlefields and that kind of thing.
41:53
So I think I've always just been interested.
41:55
And I don't know, people who write books are like World War II and have good female protagonists.
42:02
I love historical fiction as well. When you had celiac disease,
42:06
when that was discovered as a child, is that what inspired you to become a GI
42:09
doctor? Yeah, so it definitely played a role.
42:11
Just from an early age, being exposed to that field and the fact that they get
42:18
to do procedures and use their hands but don't have to be in an OR,
42:21
I think that was very enticing to me.
42:23
But honestly, in medical school and even starting residency,
42:28
I thought I was just going to be a general internist.
42:31
But then later on during internal medicine, I realized that general medicine
42:36
wasn't sustainable as well for me and for my family, the future.
42:41
And I wanted to be a specialist. And GI was always in the back of my mind.
42:46
And then being exposed to the variety of,
42:49
Things that I got to do, I got to sit with patients and talk about their gut-brain
42:54
access issues in clinic to dealing with acute bleeders in the hospital,
42:59
to just doing prevention and screening colonoscopies.
43:02
It's just a very wide breadth that keeps me entertained and varied every day.
43:08
It sounds like it's going very well.
43:09
Yes, I'm very happy where I am, and I'm glad I chose GI.
43:15
So you see patients at the UT Health Medical Arts and Research Center or the
43:20
MARC RBG, University Health's clinic downtown, Robert B. Green.
43:26
And then you're also going to start doing colonoscopies at UT Health's new multi-specialty
43:31
research hospital. Correct. Yes.
43:32
And then we're always here at University Hospital in the inpatient on the inpatient.
43:37
You have clinic there, too?
43:38
Not clinic. We do clinic mainly in the outpatient RBG system.
43:42
But then when you're on call, we're on call on consults.
43:45
We are here at University Hospital. I know you're on call this week. How's that going?
43:49
It's good. I was speaking earlier that I kind of secretly like being on call over holidays.
43:55
It's a little bit quieter and can really focus.
43:58
And I don't know. I feel like I'm kind of like secret. I don't know,
44:03
like secretly in the hospital.
44:05
Yes, I know that. Like being overnight. I don't know.
44:08
It's just kind of fun. When I was a news reporter, like working over the holiday,
44:13
too, you can feel like that.
44:14
Like it's I know what you mean. It's like quieter. Yeah.
44:17
Yeah. Unless you're covering the airports over Thanksgiving or something.
44:20
Right. So forget it. Please no.
44:22
So but yeah, no, it's good. And somebody somebody's got to cover the holidays and I'm happy to do it.
44:28
That's great. Is there anything else you want to mention that you do to unplug?
44:32
Anything like anything you're watching that we should check out?
44:35
Yeah. You know, I honestly, I don't really watch TV.
44:39
So I don't really know anything about the show's out. I know there's like a
44:43
new Great British Bake Off.
44:45
That's like the only thing I've like watched in a long time.
44:48
But I listen a lot to podcasts and audio books.
44:53
But typically I'm more just outside hanging out, throwing the footballs with my sons.
44:58
I run a lot and do a lot of hiking and just kind of outdoor activities.
45:05
And eight-year-olds are really
45:07
busy. Yes. I remember that. My son is in every sport you could name.
45:12
And so after work, I'm the chauffeur.
45:18
Can you give us anything else for the inside scoop? Do you avoid alcohol or
45:24
only drink a certain amount per week and no sodas, not even sparkling water?
45:30
Like anything inside Scoop you can tell us or how often should we be exercising? Like, yeah.
45:36
Well, for exercise, I'm a big proponent of you got to keep your body active,
45:40
not just to look good and feel fit.
45:42
But I think for mental health, it is like the number one treatment.
45:48
So I think that that's really important.
45:50
And with that, I mean, at least even just getting outside. I think we just don't
45:54
get outside enough. Take the nature bath. Putting the phone down.
45:57
I'm OK if you put your headphones in and listen to something.
46:01
But just not staring at a screen, just walking around, being outside, I think is so essential.
46:06
In regards to diet and drinking and that sort of thing, I personally don't drink
46:11
that much just because I don't really, I haven't honestly, because of celiac
46:15
disease, I wasn't able to drink a lot growing up.
46:17
And so I never really established a taste for it or a need for it.
46:21
Is there gluten in beer and a lot of kind of the hard liquors?
46:25
I can do wine. I enjoy a glass of wine every now and then.
46:27
But, of course, you know, limiting it to, you know, I would say kind of at most
46:32
a glass a day if you enjoy drinking. to kind of decompress at the end of the day.
46:38
But more than that, you got to kind of ask yourself, is this needed and should
46:43
I be doing this for my health and risks of alcohol intake?
46:48
And then if it's something like I saw my son, there was a can of Red Bull.
46:52
It was this giant can and all these ingredients I couldn't really even pronounce.
46:56
Like that's probably not good if we can't pronounce it. We don't know. Right. No, I agree.
46:59
And that stuff, I mean, I know my husband, when he does transplant cases over
47:03
the middle of the night, he's downing those things to get him through the night.
47:08
But I think on a daily basis, we need to stay away from those.
47:11
And plus, I mean, it's important to know that caffeine, alcohol,
47:14
all those can cause GI symptoms. We know for a fact that they worsen reflux disease.
47:20
So and then if they're carbonated beverages and you're adding more gas into
47:25
your system, and if you're already complaining of bloating and you're drinking
47:28
a six pack a day of Coke, you know, I mean.
47:32
We got to talk about that. You know, there could be, there's not really a medicine
47:35
to treat that. That's a avoidance of your soda.
47:38
So, I mean, I think once again, we just have to be aware that what we're putting
47:43
into our bodies can be causing a lot of our symptoms.
47:46
And if it's keeping you going and it's not affecting your quality of life, then okay.
47:51
But otherwise, like, you probably should stop. So that's true.
47:55
Is sparkling water better, a lot better than, like, there's no comparison to
47:59
soda or is it still kind of not the, as good as water.
48:03
I mean, I'm always a big proponent of just having your water bottle next to
48:06
you and just drinking water all day long.
48:07
But if you like that carbonated feel, then going for carbonated water is going
48:13
to be much better than a soda, diet or regular.
48:16
Yeah, diet sodas aren't good for us. Even diet, yeah.
48:19
I mean, granted, a lot of people, if they just cut soda out of their life,
48:24
could lose a lot of weight, just cutting those calories out.
48:26
So in that case, you know, diet could be beneficial.
48:29
But there's other, and I don't know the exact health complications of diet soda
48:32
intake, but I know that there's evidence out there that...
48:52
Quantity and what you also prioritize in your home and what about those hot
48:56
i forgot what they're called hot cheetos and like gosh i know those are those
49:00
are like the most unappetizing thing to me me too and they're so my children
49:04
just i mean that they want those they beg for those when we're at the store
49:07
but they're they look gross they look gross yes yeah,
49:11
Agreed. Anything else that you want to say about, like, why is gut health especially
49:17
important for girls and women and why it's different from what we see in boys and men? Definitely.
49:22
I think, you know, females need to be aware of their gut symptoms and also understand
49:30
that there can be a relationship between gut health and mental health.
49:34
And, you know, from early on, girls are going through lots of stressors,
49:37
especially during puberty.
49:39
And understanding that connection is very important. We know that there's irritable
49:43
bowel syndrome, which is disorder of the gut-brain axis.
49:47
And so managing both the mental health symptoms can help with the gut symptoms as well.
49:54
And gut-brain axis, it sounds like a complicated term. It's really how it interplays
50:01
what is going on with our brain, how it affects our gut, and vice versa. Exactly. Exactly.
50:06
And it can be a cycle. And I explain it many times to my patients as an irritation of the nerves.
50:13
Irritation of the nerves in the brain, those same nerves are what go to the gut.
50:18
And so irritation of the gut can cause GI symptoms.
50:21
Irritation of the nerves in the brain can cause anxiety or depression.
50:24
And so that's a really important thing to address early on, and especially kind
50:29
of in that teenage population.
50:30
And then importantly, too, is that during that time and when females start having
50:35
menstrual cycles, that there's hormonal differences from males that we have
50:40
to be aware of that can cause worsening GI symptoms.
50:43
And so, you know, estrogen, we know, can affect how fast the colon moves and
50:50
how the gut barrier is protected.
50:54
And so you could be more susceptible to constipation, for example,
50:58
or bloating. So that's important to note.
51:02
And then I think also it's just important to know that there is a connection, too, between estrogen.
51:09
The gut and then also gynecological issues. And especially, you know,
51:14
during that developmental period, knowing that abdominal pain is not necessarily
51:20
just related to intestines or the stomach, that there could also be some sort
51:24
of gynecologic issue going on, too.
51:26
So having that interdisciplinary care, making sure that they have gynecological
51:31
follow-up could be important.
51:32
And menopause, perimenopause can also affect our guts. Exactly, exactly.
51:37
And you could be more susceptible to having more symptoms from an irritable
51:40
bowel syndrome because of decreased protection of our gut barrier with the low
51:45
levels of estrogen and just having more,
51:49
be more sensitive to certain normal processes within our gut,
51:53
like the movement and the digestion and production of gas that's normal for
51:59
us could be seen as pain or significant bloating or decreased appetite, that sort of thing.
52:06
And a stomach ache could be something we ate. It could be a virus. It could be H. pylori.
52:11
Something called H. pylori. Exactly, yeah. And H. pylori is a bacteria.
52:15
It's very, very common and is important if you do have some sort of GI symptoms
52:20
to be tested for, which can be done non-invasively through a stool or a breath
52:26
test or endoscopically through biopsies of the stomach wall.
52:30
But that's something that we can treat with antibiotics and can cure it,
52:33
and some of the GI symptoms can go away with that.
52:36
So as a mom and doctor with so much knowledge, we've talked about how you stay away from probiotics.
52:45
Are there any other nuggets of prevention and gut health for you or your kids
52:49
that you want to mention before we wrap up?
52:52
I personally have a very open conversation with my kids about their poop, about how they feel.
52:59
And I grew up that way as well. My parents weren't GI doctors,
53:04
but we were just very open about it.
53:05
And your mom was a pediatrician? My mom was a pediatrician, yes.
53:07
My dad was a neurologist.
53:08
So we had medical backgrounds, but we were just very open, which can be seen as weird by some people.
53:15
But I think it honestly is helpful because— You talk about poop at the dinner
53:18
table. We talk about poop.
53:19
We, you know, my son lets me know when he needs to go poop, that sort of thing.
53:22
But I also am aware of his gut health.
53:26
You know, I know that he is able to have a bowel movement every day.
53:29
He's comfortable telling me when he's struggling to have a poop.
53:34
And I know maybe he's, you know, oftentimes it's when he hasn't had any water
53:38
to drink. He's not eating as healthy as he has been. So I know that I need to maybe adjust that.
53:44
But I think having an open conversation and not making it seem like it's something
53:48
scary to talk about is really important.
53:51
And then as kids get older, too, you know, specifically, you know,
53:55
maybe going through that puberty, going into having starting having the menstrual
53:59
cycle, something like that, they're having more significant GI symptoms.
54:02
Your kids might be more open to talk
54:03
about it. And then if it needs to be investigated, it can be investigated.
54:07
Do you want to mention before, just briefly, like what's some of the language you use?
54:12
Like where us non-doctor parents, we might be a little nervous in talking about
54:17
poop with our kids. Yeah.
54:18
I mean, I think just letting them, I will let them know like,
54:22
hey, I, you know, I need to go poop. I'm going to go sit on the toilet and go poop.
54:25
You say that? I say that. Yeah. Because it's also, you know,
54:29
I don't want them standing there watching me.
54:30
You know, like I'm going to say, okay, this is my time. I'm gonna go poop.
54:33
I'll be back. This is my time.
54:34
This is my time. And don't talk to my husband about his my time.
54:38
You know, he'll be there for, you know, forever on his phone,
54:40
which is I don't recommend. It's not healthy. Do not sit on the toilet with your phone on.
54:44
But eat more fiber, eat more fiber. Yeah. And don't sit on the toilet because
54:48
of all that pressure and straining and just being on the toilet. It's not good.
54:52
But I think I think just kind of just freely openly talking about if you don't
54:56
like poop, maybe you have another word for it or,
54:59
you know, something like that, but making the kids feel comfortable and not
55:03
that it's like an embarrassing thing to have to go to the bathroom or because
55:07
we know that kids, you know, can hold it in and they're scared to go, that sort of thing.
55:12
Might have accidents, but just kind of normalizing it like, you know, this is okay.
55:17
We're learning how to use the toilet correctly. It's okay. You got messy.
55:21
We'll clean your clothes. We'll wipe you down. We'll try again.
55:24
You know, let me know if I can help you. Just making it a part of our normal
55:28
life, just like learning how to ride a bike or learning how to use a fork or something.
55:32
You know, there's going to, we have to teach those practices and make it normal.
55:37
I love it. That's great advice. And we can't forget to take care of ourselves.
55:41
Yes, exactly. We have to focus on ourself. It's hard.
55:45
It's hard to do. And oftentimes it's 10 o'clock at night when we realize,
55:48
oh, I need to take care of myself.
55:50
But just understanding what's going on with our own body so we know when something's going off, we know.