Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / What's the deal with poop?

Transcript

What's the deal with poop? · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:00
  Speaker 1: Before we get started today, a quick correction on our
• 0:03
  Speaker 1: tick episode. Hat tip to Parker Hudson, infectious disease doctor
• 0:08
  Speaker 1: and Hospital University of Pennsylvania alumnus like me, who pointed
• 0:13
  Speaker 1: out that the International Infectious Disease Society only recommends prophylactic
• 0:18
  Speaker 1: antibiotics for prevention of Lyme disease for high-risk tick bites,
• 0:23
  Speaker 1: which means that it's an Ixodes species tick, so like
• 0:27
  Speaker 1: a deer tick. that you live in a highly endemic
• 0:29
  Speaker 1: area and that it was attached for more than 36 hours. Otherwise,
• 0:33
  Speaker 1: the ID Society says just watch and wait.
• 0:37
  Speaker 2: Perry, do men take longer to poop than women?
• 0:43
  Speaker 1: I have no idea. Do they? Do I?
• 0:47
  Speaker 2: Well, fun fact.
• 0:50
  Speaker 1: Because I'm browsing my phone.
• 0:51
  Speaker 3: All mammals pretty much poop in about 12 seconds. So actually,
• 0:56
  Speaker 3: it doesn't take very long. to poop, but the data
• 1:01
  Speaker 3: does suggest that men spend more time in the bathroom.
• 1:04
  Speaker 3: And one time a men's magazine did a highly, highly
• 1:08
  Speaker 3: scientific survey of what was happening in there.
• 1:12
  Speaker 2: And it was that they were reading on their phone.
• 1:15
  Speaker 1: Oh, is that what they said?
• 1:17
  Speaker 2: That is what they said. Yes. Fine. Yes, everyone.
• 1:20
  Speaker 1: That's what we're doing. I have, uh, I have my
• 1:23
  Speaker 1: copy of Wittgenstein right by the toilet, and I like
• 1:28
  Speaker 1: to get a few chapters in, in peace. Sorry, not sorry.
• 1:31
  Speaker 2: 12 seconds. 12 seconds is what you get.
• 1:34
  Speaker 1: All right. Well, I have poop and superiority complex already
• 1:37
  Speaker 1: as we start our now two episodes in a row.
• 1:41
  Speaker 1: We've done tics, now poop. Sort of like an ick themed.
• 1:46
  Speaker 2: I could not be more excited.
• 1:47
  Speaker 3: I do not think people talk enough about their poop,
• 1:49
  Speaker 3: and I can't wait to discuss more about it.
• 1:51
  Speaker 1: I'm good. I'm glad you're poop positive. I am poop skeptical,
• 1:55
  Speaker 1: but I hope that after this episode, we'll all be
• 1:58
  Speaker 1: more comfortable with that most natural of human bodily functions.
• 2:06
  Speaker 2: I'm Emily Oster. I'm an economist and a data expert.
• 2:09
  Speaker 1: And I'm Perry Wilson. I'm a medical doctor.
• 2:11
  Speaker 2: It's Thursday. September 3rd, 2026. And this is Wellness Actually.
• 2:17
  Speaker 1: Because you're getting a staggering amount of health and wellness
• 2:20
  Speaker 1: information nowadays from every source imaginable. And some of it
• 2:24
  Speaker 1: is awesome.
• 2:25
  Speaker 2: And some of it is, well, actually bullshit.
• 2:29
  Speaker 3: Fortunately, we're both people who know how to read studies,
• 2:33
  Speaker 3: how to parse the data, and can tell you what's
• 2:35
  Speaker 3: worth thinking about and what you can safely ignore.
• 2:38
  Speaker 1: But before we dig in, a note that this podcast
• 2:40
  Speaker 1: is for educational purposes and should not be construed as
• 2:43
  Speaker 1: medical advice. We don't know your unique situation, so talk
• 2:46
  Speaker 1: to your doctor for personal health decisions.
• 2:50
  Speaker 3: This week, we're asking, what's the deal with poop? Perry
• 2:53
  Speaker 3: and I will give the official smash or pass, and
• 2:55
  Speaker 3: then we'll get to your question of the week. But first,
• 2:57
  Speaker 3: let's do the health news roundup after the break. And
• 3:11
  Speaker 3: now for the health news of the week. The first
• 3:14
  Speaker 3: thing I wanted to talk about was rabies. Rabies is
• 3:18
  Speaker 3: completely terrifying. It's one of the things I am the
• 3:20
  Speaker 3: most afraid of. And it now seems like maybe it's underreported.
• 3:26
  Speaker 2: Say more.
• 3:27
  Speaker 1: Yeah.
• 3:27
  Speaker 3: Yeah.
• 3:28
  Speaker 1: Rabies is super scary because it is a disease without
• 3:31
  Speaker 1: a cure that's uniformly fatal. That's what everyone needs to know.
• 3:35
  Speaker 1: If you need to know anything besides that, you need
• 3:37
  Speaker 1: to know that rabies has a rather long latent period
• 3:40
  Speaker 1: between the bite or even like people have been scratched
• 3:43
  Speaker 1: and contracted rabies and the time it manifests with symptoms.
• 3:48
  Speaker 1: When you hit symptoms, it's basically over. But if you
• 3:52
  Speaker 1: get vaccinated after the bite, but before symptoms develop, you
• 3:56
  Speaker 1: can almost always be protected from rabies. So that's what
• 4:00
  Speaker 1: people need to know. Rabies is very uncommon, though. From
• 4:02
  Speaker 1: 2000 to 2024, there were 60 reported cases in the US.
• 4:07
  Speaker 1: 59 of those were fatal. The one exception is a
• 4:10
  Speaker 1: woman named Gianna Geese in 2004, who underwent this special protocol,
• 4:18
  Speaker 1: was in an induced coma for a very long time.
• 4:20
  Speaker 1: But I just checked up. She's living a normal life now,
• 4:22
  Speaker 1: sort of a miracle. She's like the only rabies survivor.
• 4:25
  Speaker 1: Fascinating story. But a new study just came out in
• 4:28
  Speaker 1: Nature Communications that says that those 60 cases is a
• 4:31
  Speaker 1: fairly dramatic undercount. They estimate, in fact, that there have
• 4:36
  Speaker 1: been 856 cases of rabies over that time period. And
• 4:41
  Speaker 1: the way they are estimating that is what's kind of
• 4:44
  Speaker 1: interesting about this study and actually pertains to my neck
• 4:47
  Speaker 1: of the woods. Because every once in a while when
• 4:49
  Speaker 1: you transplant an organ into a new person, that organ
• 4:54
  Speaker 1: has a disease that you didn't test for. You didn't
• 4:56
  Speaker 1: know it had. And of course, then you put that organ,
• 4:59
  Speaker 1: like a terrible example would be like HIV. I mean,
• 5:02
  Speaker 1: obviously we test for HIV, but there've been rare cases
• 5:04
  Speaker 1: where tests have been false negatives or whatever. And like
• 5:07
  Speaker 1: you transplant that organ into someone, not only do you
• 5:09
  Speaker 1: transplant the infected organ, but you're immunosuppressing the recipient because
• 5:13
  Speaker 1: they're getting a transplant. It's a perfect storm really for
• 5:16
  Speaker 1: these infections to crop up. And there have been three
• 5:21
  Speaker 1: instances where, of undiagnosed rabies in a brain-dead donor, which
• 5:27
  Speaker 1: only came to light after that brain-dead donor had their
• 5:30
  Speaker 1: organs transplanted into other people. There was one most recently
• 5:35
  Speaker 1: in February 2025 where the exposure was the donor had
• 5:39
  Speaker 1: been scratched by a skunk. Okay, so what the researchers
• 5:42
  Speaker 1: did is they were like, okay, we know how many
• 5:44
  Speaker 1: deceased donors there have been over this time period. There
• 5:47
  Speaker 1: have been 239,251. We know that three of them had
• 5:50
  Speaker 1: rabies that we weren't aware of. And if you scale
• 5:54
  Speaker 1: that up to the, if you assume that their rate
• 5:56
  Speaker 1: of rabies is the same as the general population, then
• 6:02
  Speaker 1: we scale that 239,000 up to the general population, we
• 6:05
  Speaker 1: get 856 cases. The idea here being that every once
• 6:09
  Speaker 1: in a while, people come in, like how this would
• 6:12
  Speaker 1: manifest is as an encephalitis, a brain infection, that person
• 6:17
  Speaker 1: comes in. And if you don't test for rabies, you
• 6:22
  Speaker 1: might not know it's rabies, right? You would just say,
• 6:23
  Speaker 1: oh my gosh, they have some horrible encephalitis. You do
• 6:25
  Speaker 1: a bunch of tests, but maybe you don't hear a
• 6:28
  Speaker 1: story about an animal exposure, right? That's the problem. A
• 6:31
  Speaker 1: bat was flying around their house. They don't even know
• 6:33
  Speaker 1: they were bitten or something like that. The person invariably
• 6:37
  Speaker 1: dies because they have symptoms. Rabies is uniformly fatal. And
• 6:41
  Speaker 1: you go to transplant their organs, or in the case
• 6:43
  Speaker 1: of the people that don't go on to donate, they
• 6:45
  Speaker 1: just die and it gets listed as encephalitis. It's not
• 6:48
  Speaker 1: actually easy to test rabies. You have to send the
• 6:50
  Speaker 1: test to the CDC or like certain state labs can
• 6:53
  Speaker 1: do it. But generally, your hospital can't do it. You
• 6:56
  Speaker 1: need to kind of be aware of it. And so, yeah,
• 7:00
  Speaker 1: we might be missing. I mean, it's still not many,
• 7:02
  Speaker 1: but might be missing more rabies cases than we are
• 7:05
  Speaker 1: aware of. And maybe people should be aware of it.
• 7:09
  Speaker 3: I do think people should be aware. I will say
• 7:10
  Speaker 3: I want to like dial down the numbers. I want
• 7:13
  Speaker 3: to like.
• 7:13
  Speaker 1: Just be clear. Dial it up. Dial it up.
• 7:16
  Speaker 2: We're engaging our listeners.
• 7:19
  Speaker 3: Because this is still not that many cases and it
• 7:22
  Speaker 3: is still really something you can do something about. So
• 7:25
  Speaker 3: if there is a bat in your house, even if
• 7:29
  Speaker 3: you do not know that you were bitten by it,
• 7:31
  Speaker 3: it is worth discussing with your doctor whether you should
• 7:34
  Speaker 3: get a rabies vaccine.
• 7:36
  Speaker 2: It's not that bad.
• 7:37
  Speaker 3: One time we found a dead bat in a guest
• 7:40
  Speaker 3: house that we were staying in. And my entire family
• 7:42
  Speaker 3: got like the full on rabies situation. And, you know,
• 7:47
  Speaker 3: that's a giant needle, but it was totally fine.
• 7:49
  Speaker 4: Yeah. Yeah.
• 7:51
  Speaker 1: And it's not just bats. Any mammal really. Any mammal.
• 7:54
  Speaker 1: Very small mammals usually die before they can bite you.
• 7:56
  Speaker 1: So like mice and stuff like that. But certainly skunks.
• 7:59
  Speaker 1: I think possums famously are like don't get rabies, but
• 8:02
  Speaker 1: still any strangely behaving mammal. that you have an interaction
• 8:06
  Speaker 1: with is something to be worried about. And as we say,
• 8:09
  Speaker 1: you put this off and once those symptoms start, and
• 8:11
  Speaker 1: it might be weeks, it might even be a couple
• 8:13
  Speaker 1: of months after exposure, it's over.
• 8:17
  Speaker 2: Yeah. Okay. It's scary.
• 8:19
  Speaker 3: Great.
• 8:19
  Speaker 1: All right. Emily, I debated whether I wanted to put
• 8:24
  Speaker 1: this on the list, but there's been so much talk
• 8:27
  Speaker 1: about the measles deaths in Pennsylvania that I think we
• 8:32
  Speaker 1: just have to weigh in here. So why don't you
• 8:36
  Speaker 1: walk me through what's going on with measles writ large
• 8:39
  Speaker 1: and why is there so much consternation over these two,
• 8:43
  Speaker 1: perhaps measles related, perhaps measles associated deaths in Lancaster County?
• 8:50
  Speaker 3: So I think it's important to start by setting the
• 8:53
  Speaker 3: stage that we have had more measles this year that
• 8:57
  Speaker 3: in many, many, many, many previous years, we've had 2,777
• 9:02
  Speaker 3: so far this year. It's the most since the early 1990s.
• 9:06
  Speaker 3: The previous record since then was set last year. And
• 9:09
  Speaker 3: there was a week in January of 2026 when there
• 9:12
  Speaker 3: were more measles cases in that week than in most
• 9:16
  Speaker 3: of the previous 20 years for the whole year.
• 9:19
  Speaker 1: It's very contagious. We've said that a couple of times.
• 9:23
  Speaker 2: It's really contagious.
• 9:24
  Speaker 3: And so we are clearly seeing more measles and that
• 9:26
  Speaker 3: is not a, there is no debate about that. There
• 9:29
  Speaker 3: is also no debate about the fact that measles can
• 9:32
  Speaker 3: kill you. So depending on the population that you're looking at,
• 9:36
  Speaker 3: estimates of mortality are something like one in a thousand.
• 9:40
  Speaker 3: Some of that mortality is actually longer term. So measles
• 9:44
  Speaker 3: has impacts on your immune system that can cause death later.
• 9:49
  Speaker 3: For kids who have had it, it may die later.
• 9:51
  Speaker 3: So measles is definitely more around. It is also a
• 9:54
  Speaker 3: potentially fatal disease. Most people don't die of measles. So
• 9:58
  Speaker 3: most people... I mean, most people don't die of measles,
• 10:01
  Speaker 3: but also most people who get measles don't die of it.
• 10:04
  Speaker 2: So those things are all true.
• 10:06
  Speaker 3: We are now having an argument about two particular cases
• 10:11
  Speaker 3: of deaths in Pennsylvania that may or may not have
• 10:15
  Speaker 3: been associated with measles. And part of what's hard about
• 10:19
  Speaker 3: this is that sometimes when people die of things, it's
• 10:23
  Speaker 3: not actually that obvious precisely what they died of. And
• 10:28
  Speaker 3: for example, when people die of HIV or AIDS, they
• 10:31
  Speaker 3: are typically dying of something else. There's a cancer, there's
• 10:34
  Speaker 3: something else that affected their immune system, but the underlying
• 10:38
  Speaker 3: cause is the HIV virus. In this particular case, there
• 10:43
  Speaker 3: are two measles-associated deaths. One of them I think we
• 10:47
  Speaker 3: know almost nothing about. The other is a baby. And
• 10:52
  Speaker 3: it's pretty clear now actually what happened. The Atlantic did
• 10:55
  Speaker 3: some amazing reporting on this where they went and they
• 10:57
  Speaker 3: talked to the family. What happened is the mom and
• 11:00
  Speaker 3: some of the other children in the family had very
• 11:02
  Speaker 3: serious measles cases.
• 11:05
  Speaker 2: Shortly after that, The mom gave birth.
• 11:08
  Speaker 3: The baby had a lacerated spleen, which is not a
• 11:12
  Speaker 3: very common thing that happened, but can happen potentially as
• 11:17
  Speaker 3: a result of maternal measles infection. The baby died, and
• 11:22
  Speaker 3: that's what happened. And so it's kind of ambiguous whether
• 11:28
  Speaker 3: you want to say that's because of measles or not.
• 11:30
  Speaker 2: It's not.
• 11:32
  Speaker 3: Because a three-month-old baby got infected with measles and then
• 11:35
  Speaker 3: died of measles, it's not that straightforward. It also seems
• 11:38
  Speaker 3: very likely that the serious measles infection in mom was
• 11:42
  Speaker 3: a factor in the death. And the reality is that
• 11:47
  Speaker 3: there is a baby that died, and that is extremely sad.
• 11:51
  Speaker 3: And these facts I said about measles are true at
• 11:53
  Speaker 3: the beginning. And This whole thing is so political in
• 11:59
  Speaker 3: a way that is very frustrating from a public health standpoint.
• 12:03
  Speaker 1: Yeah, it's ghoulish, right? You know, we're picking through these
• 12:07
  Speaker 1: little tidbits of information that you get and you don't
• 12:10
  Speaker 1: have adequate information. You know, a lacerated spleen, as you say,
• 12:14
  Speaker 1: is incredibly rare. It can happen through birth trauma. It
• 12:17
  Speaker 1: can also happen because of spleen enlargement. which can happen
• 12:21
  Speaker 1: for measles now. The coroner was like, well, the spleen
• 12:23
  Speaker 1: wasn't enlarged, but actually if it's bleeding, it can be
• 12:26
  Speaker 1: hard to tell if the spleen was enlarged because it
• 12:28
  Speaker 1: kind of deflates if it's bleeding. And so you have
• 12:30
  Speaker 1: to weigh it and we don't know the weight of
• 12:31
  Speaker 1: the spleen. Like we could go on and on and on.
• 12:33
  Speaker 1: And in the end, this mom was sick enough to
• 12:36
  Speaker 1: be in the hospital. I mean, it does appear like
• 12:38
  Speaker 1: this was a preterm birth. We still don't know whether
• 12:40
  Speaker 1: it was a C, like what the, whether it was
• 12:43
  Speaker 1: a C-section or a vaginal delivery. Like, honestly, at this point,
• 12:47
  Speaker 1: I'm like, okay, you know, The unambiguous fact is that
• 12:51
  Speaker 1: we're doing a poor job controlling an ongoing and growing
• 12:55
  Speaker 1: measles outbreak.
• 12:56
  Speaker 2: That's it. That's the whole thing.
• 12:58
  Speaker 1: And this is not like the early days of COVID
• 13:02
  Speaker 1: when we're like, ah, what do we do? How do
• 13:04
  Speaker 1: we stop this? Do we isolate? Do we mask? Do
• 13:07
  Speaker 1: we try hydrochloroquine? All these things. We've known how to
• 13:10
  Speaker 1: do this for decades and decades and decades. It requires vaccination.
• 13:14
  Speaker 1: Because measles is so infectious, it requires vaccination. a lot
• 13:18
  Speaker 1: of vaccination to achieve something like herd immunity. And the broad,
• 13:24
  Speaker 1: you know, RFK Jr. and other administration officials will pay
• 13:28
  Speaker 1: lip service to being like, oh, I'm not anti-vax, I'm
• 13:30
  Speaker 1: not anti-vax. But then, you know, kicking up a firestorm
• 13:35
  Speaker 1: like this seems just like it almost feels like they're
• 13:39
  Speaker 1: looking for an excuse to say, oh, no, you know,
• 13:42
  Speaker 1: don't worry, right? Measles is not a big deal. So
• 13:46
  Speaker 1: it's okay if you're not getting vaccinated. And whether or
• 13:50
  Speaker 1: not these kids would have died had they not had measles,
• 13:54
  Speaker 1: this counterfactual that is impossible to test, it's still bad.
• 13:58
  Speaker 1: There's other things that can happen. Measles can cause encephalitis.
• 14:01
  Speaker 1: Measles cause secondary pneumonia, missed school. Measles can cause this
• 14:04
  Speaker 1: immune memory loss where it makes you more susceptible to
• 14:07
  Speaker 1: other infections for years afterwards. It's just like not good.
• 14:11
  Speaker 1: And we have a solution. It just seems like we're
• 14:14
  Speaker 1: cutting off our nose to spite our face here.
• 14:16
  Speaker 2: It's very frustrating and also very sad. And I'm not
• 14:21
  Speaker 2: sure how much there is to say about this.
• 14:23
  Speaker 1: The one thing I will say, I'll always have one
• 14:26
  Speaker 1: more thing to say, is just because people might be
• 14:28
  Speaker 1: wondering that Newborns can't get the MMR vaccine. I mean,
• 14:33
  Speaker 1: one of the reasons that we worry about measles outbreaks
• 14:37
  Speaker 1: is that because the MMR is a live attenuated vaccine,
• 14:39
  Speaker 1: there are a lot of people who can't get it,
• 14:41
  Speaker 1: including babies until they're nine months old. And then people
• 14:44
  Speaker 1: who are immunocompromised, who have transplants and things like that,
• 14:48
  Speaker 1: which is why herd immunity might be important to protect them. Obviously,
• 14:51
  Speaker 1: the mother could have gotten vaccinated at some point. Generally,
• 14:55
  Speaker 1: we don't recommend vaccination during pregnancy.
• 14:57
  Speaker 2: Sorry, can I correct some of this?
• 14:59
  Speaker 4: Please, yeah.
• 15:00
  Speaker 3: So the reason we do not vaccinate newborns for the
• 15:04
  Speaker 3: measles is because they will not develop immunity until sometime
• 15:08
  Speaker 3: after the maternal immunity wears off. So they have some
• 15:11
  Speaker 3: immunity from their mom for about the first six months,
• 15:13
  Speaker 3: sometime between six and 12 months that wears off. But
• 15:16
  Speaker 3: if you vaccinate them before that, it doesn't actually prompt
• 15:18
  Speaker 3: their own immunity. So you can give your infant a
• 15:21
  Speaker 3: measles vaccine as early as six months. then you need
• 15:25
  Speaker 3: another dose at 12 months and another dose more than
• 15:27
  Speaker 3: three months after that. So there are some ways to
• 15:30
  Speaker 3: protect the baby. And very small infants are generally protected
• 15:33
  Speaker 3: to some extent by their mother's MMR titers.
• 15:36
  Speaker 1: Very nice. Thank you. Appreciate that. All right. Let's move on.
• 15:41
  Speaker 1: That is it for the health news of the week.
• 15:45
  Speaker 1: Now for something completely different. Emily, what's the deal with poop?
• 15:53
  Speaker 2: I'm so excited to talk about it.
• 15:56
  Speaker 3: So I thought a lot about how we should help
• 15:59
  Speaker 3: people understand this and what is really the kind of
• 16:02
  Speaker 3: question here. And I think I want to frame the
• 16:05
  Speaker 3: question as like, is poop a window to your soul?
• 16:10
  Speaker 3: How much can we learn about ourselves by our poop?
• 16:15
  Speaker 3: And in the U.S., we're not really that into talking
• 16:17
  Speaker 3: about it. Like, people don't like to talk about it.
• 16:19
  Speaker 3: But that's not true in every culture. Some cultures are
• 16:21
  Speaker 3: much more into discussing, like, the details of their poop.
• 16:25
  Speaker 1: My wife is Jewish. I don't know if you're including
• 16:28
  Speaker 1: that as a culture.
• 16:29
  Speaker 2: But, yeah.
• 16:30
  Speaker 1: It's disgusting. It is disgusting.
• 16:36
  Speaker 3: So this whole episode, I think we should think of
• 16:38
  Speaker 3: that frame. We're going to ask, you know, is poop
• 16:40
  Speaker 3: a window to your soul? And how much can we
• 16:43
  Speaker 3: learn from your poop?
• 16:46
  Speaker 1: I love it.
• 16:47
  Speaker 2: All right.
• 16:48
  Speaker 1: Talk to me.
• 16:49
  Speaker 2: No, you talk to me. You're the doctor. Let's start
• 16:52
  Speaker 2: with science. Tell me what is my poop?
• 16:55
  Speaker 4: Oh, okay.
• 16:56
  Speaker 1: That I can answer. I can't answer whether it's part
• 16:59
  Speaker 1: of your soul, but I can tell you what's in it.
• 17:02
  Speaker 4: Okay.
• 17:03
  Speaker 1: So this is what's poop. It's water. Of differing amounts,
• 17:07
  Speaker 1: depending on how much is reabsorbed by your colon. It
• 17:10
  Speaker 1: is sloughed, sloughed, sloughed epithelial cells. So sort of the
• 17:16
  Speaker 1: lining of your colon as the poop passes through, it's
• 17:20
  Speaker 1: a bunch of fiber from the food that you eat
• 17:22
  Speaker 1: and can't digest. And then it is bacterial biomass. And
• 17:28
  Speaker 1: you may wonder about the color and the smell. There's
• 17:30
  Speaker 1: some interesting science here. So it is generally brown. because
• 17:37
  Speaker 1: of something called stercobilin, which is bilirubin metabolite. So this
• 17:42
  Speaker 1: actually comes from the heme in your red blood cells.
• 17:45
  Speaker 1: As red blood cells get broken down in your body,
• 17:47
  Speaker 1: the heme, which is iron-containing, gets released and that gets
• 17:50
  Speaker 1: metabolized into bilirubin and other things. That comes out in
• 17:53
  Speaker 1: your stool and it has a brownish color. We'll talk
• 17:55
  Speaker 1: later about maybe what colors of stool are something to
• 17:59
  Speaker 1: be alarmed about. And then there's the smell, the odor,
• 18:05
  Speaker 1: which is there. Some of that is hydrogen sulfide, the
• 18:08
  Speaker 1: same smell that you get from rotten eggs, which comes
• 18:12
  Speaker 1: from bacterial metabolism. But actually, a fun fact, part of
• 18:17
  Speaker 1: the smell is a bacterial product called scatol, which gives
• 18:24
  Speaker 1: a particularly characteristic human poop smell. And little known fact,
• 18:29
  Speaker 1: scatol is a somewhat popular additive to perfumes because in
• 18:37
  Speaker 1: very small amounts it apparently has like a bit of
• 18:39
  Speaker 1: a florally musk scent to it. And yet another example
• 18:44
  Speaker 1: of the dose makes the poison coming to you from
• 18:47
  Speaker 1: the Wellness Actually podcast.
• 18:48
  Speaker 2: That's kind of gross. Actually, I find that gross. Okay.
• 18:52
  Speaker 2: All right.
• 18:53
  Speaker 1: I thought we were going to be poop positive. We're
• 18:55
  Speaker 1: going to be positive.
• 18:56
  Speaker 4: Okay.
• 18:56
  Speaker 1: I did look it up. I did look it up.
• 18:58
  Speaker 1: The scat hole that is in your perfume is not
• 19:00
  Speaker 1: harvested directly from poop of any kind. That is reassuring.
• 19:04
  Speaker 1: It's synthesized in a lab.
• 19:06
  Speaker 4: Cool.
• 19:06
  Speaker 5: Cute.
• 19:07
  Speaker 1: Okay. All right.
• 19:08
  Speaker 2: So that's what it is.
• 19:09
  Speaker 3: I think the core question people have before we get
• 19:12
  Speaker 3: to the window for the soul is like, is my
• 19:14
  Speaker 3: poop regular? And this is, I think, part of why
• 19:17
  Speaker 3: we should talk about it. why we should talk about
• 19:20
  Speaker 3: poop because people wonder if their.
• 19:22
  Speaker 2: Pooping is like other people's pooping and you don't know. Okay.
• 19:27
  Speaker 2: So a few things.
• 19:30
  Speaker 3: In the NHANES data, everybody's favorite nationally representative survey of Americans,
• 19:35
  Speaker 3: they ask people many things, including how often they poop.
• 19:40
  Speaker 2: And they kind of Do.
• 19:41
  Speaker 1: You ever wonder about the NHANES people when they're getting
• 19:44
  Speaker 1: together for like next year's survey and they're like, all right, guys,
• 19:47
  Speaker 1: we did alcohol intake. We did blood pressure. What's missing?
• 19:53
  Speaker 1: Someone sheepishly raises their hand. It's like, all right, anyway.
• 19:59
  Speaker 1: Go ahead. What does NHANES tell us?
• 20:00
  Speaker 2: I love the NHANES so much.
• 20:03
  Speaker 3: So in that data, the sort of typical range is
• 20:06
  Speaker 3: something like three times a day up to three times
• 20:10
  Speaker 3: a week. And the modal person is pooping once a day.
• 20:13
  Speaker 3: I actually think these numbers are a little bit misleading
• 20:16
  Speaker 3: in the sense that almost everyone is in that range,
• 20:18
  Speaker 3: including people.
• 20:19
  Speaker 2: Who are having issues with their pooping.
• 20:22
  Speaker 3: So frequency is actually not a very good discriminator about
• 20:25
  Speaker 3: whether you are sick or you're, you're healthy. So like
• 20:28
  Speaker 3: if you're pooping 15 times a day, you probably are
• 20:31
  Speaker 3: spending all of your time in the bathroom.
• 20:33
  Speaker 2: That's like a signal of a problem.
• 20:34
  Speaker 3: If you're pooping less than three times a week, that
• 20:37
  Speaker 3: is also likely a signal of constipation, but there's a
• 20:39
  Speaker 3: pretty wide range and you could be having issues with
• 20:45
  Speaker 3: your digestive system even within that range.
• 20:48
  Speaker 1: Right. Most people, even with, uh, Irritable bowel syndrome or
• 20:55
  Speaker 1: inflammatory bowel disease, significant GI problems still fall within that range.
• 21:00
  Speaker 1: So it's not actually that helpful. There's as much variation
• 21:03
  Speaker 1: between people. I think people don't talk about– well, let's
• 21:08
  Speaker 1: talk about consistency because we have to talk about the
• 21:10
  Speaker 1: Bristol stool. Bristol stool scale.
• 21:11
  Speaker 2: Bristol stool scale.
• 21:12
  Speaker 1: It's the best. The good people at Bristol have created
• 21:17
  Speaker 1: a qualitative scale to judge what your stool looks like.
• 21:25
  Speaker 1: And it ranges from type 1, which is described as
• 21:28
  Speaker 1: separate hard lumps like little pebbles, I think like rabbit
• 21:33
  Speaker 1: poop or something like that, all the way to type 7,
• 21:35
  Speaker 1: which is watery with no solid pieces. Those are both abnormal.
• 21:39
  Speaker 1: The sort of standard, I don't know, recommended healthy-ish pebbles
• 21:45
  Speaker 1: Bristol school chart are types three and four. Type three
• 21:47
  Speaker 1: is described as sausage shaped with cracks on the surface.
• 21:50
  Speaker 1: And type four is thinner and more snake-like plus smooth
• 21:54
  Speaker 1: and soft. So that's what we're looking for consistency wise.
• 22:00
  Speaker 1: And most of this is driven by water absorption, which
• 22:05
  Speaker 1: happens along the colon. Your colon reabsorbs a lot of
• 22:08
  Speaker 1: the water from your stool. And it does that based
• 22:11
  Speaker 1: on the transit time of water. passage. So like the
• 22:16
  Speaker 1: longer stool sits in there, the more water gets sucked
• 22:19
  Speaker 1: up and the drier and harder and lumpier it gets.
• 22:22
  Speaker 1: And we don't talk about transit time.
• 22:25
  Speaker 3: But transit time is interesting because it varies quite a lot. Something,
• 22:30
  Speaker 3: you know, normal transit times are something like 10 to
• 22:33
  Speaker 3: 75 hours. And that's actually a huge, I mean, that's
• 22:35
  Speaker 3: a huge range.
• 22:37
  Speaker 1: And that's mouth to toilet transit time.
• 22:39
  Speaker 3: Mouth to toilet transit time. And you can test mouth
• 22:42
  Speaker 3: to toilet transit time. By, uh, there's actually two ways. So, uh,
• 22:48
  Speaker 3: so a free way to do it is to eat corn.
• 22:51
  Speaker 3: So most people cannot digest, uh, like a lot of
• 22:54
  Speaker 3: corn kernels. So if you eat a corn on the
• 22:56
  Speaker 3: cob and then you wait to see when you see
• 22:58
  Speaker 3: the corn kernels in your poop, that's a good way.
• 23:01
  Speaker 2: It's a good metric.
• 23:02
  Speaker 3: You can also dye your poop blue. So there's different
• 23:06
  Speaker 3: commercial and other frosting related ways to do this.
• 23:09
  Speaker 1: You can do this accidentally.
• 23:10
  Speaker 2: You can do this accidentally. And that's fun. That's like
• 23:14
  Speaker 2: a fun activity.
• 23:15
  Speaker 1: Can we play a clip? Because this is getting like
• 23:18
  Speaker 1: the blue poop challenge is an Instagram thing.
• 23:21
  Speaker 2: Let me play that for you.
• 23:22
  Speaker 6: Have you done the blue poo test? The purpose of
• 23:25
  Speaker 6: this test is to see how fast the food that
• 23:28
  Speaker 6: you eat goes through you. So you make blue colored muffins,
• 23:32
  Speaker 6: you eat two of them for breakfast, and then you
• 23:34
  Speaker 6: wait to see how long it takes for your poo
• 23:36
  Speaker 6: to turn blue. This will tell you your transit time.
• 23:39
  Speaker 6: Most people should be aiming for between 14 to 50-ish
• 23:43
  Speaker 6: hours of transit time. If it takes you longer to
• 23:46
  Speaker 6: see blue poo in the toilet, it might be a
• 23:48
  Speaker 6: sign that you're constipated or that your digestion needs some work.
• 23:51
  Speaker 6: A big contributor to pelvic floor dysfunction is constipation. And
• 23:55
  Speaker 6: optimizing the transit time is one part of improving your
• 23:58
  Speaker 6: gut health and eliminating constipation.
• 24:02
  Speaker 1: So this is something you can do in the comforts
• 24:07
  Speaker 1: of your own home. What kind of food coloring to add?
• 24:11
  Speaker 1: I've seen online royal blue food coloring, right? You want
• 24:16
  Speaker 1: to dye like a muffin or something like that. And
• 24:19
  Speaker 1: the normal transit time, as you said, it's between 10
• 24:22
  Speaker 1: to 75 hours. So 10 would be sort of the
• 24:25
  Speaker 1: short end and 75 would be the long end of
• 24:28
  Speaker 1: time between eating a blue muffin and seeing some blue
• 24:31
  Speaker 1: or maybe greenish or some abnormal color coming out the
• 24:35
  Speaker 1: other end.
• 24:36
  Speaker 3: Now, having said that, like transiting your poop very quickly
• 24:40
  Speaker 3: is not like a like a life goal.
• 24:43
  Speaker 1: Right.
• 24:43
  Speaker 3: This idea that like we are trying to like poop
• 24:48
  Speaker 3: max and get our like get our. optimal frequency and
• 24:51
  Speaker 3: like have a laxative. So the poop gets out fast.
• 24:54
  Speaker 3: So like, that's not a thing you need to do.
• 24:56
  Speaker 3: So very long transit times can be associated with constipation
• 24:59
  Speaker 3: because the water gets pulled out and pulled out.
• 25:01
  Speaker 2: And so that's like something to be aware of, but.
• 25:05
  Speaker 3: You, you shouldn't be trying to take the blue poop
• 25:09
  Speaker 3: challenge and then like optimize. So the poop comes out
• 25:12
  Speaker 3: as fast as possible.
• 25:13
  Speaker 2: That's not, that's not just not healthy.
• 25:15
  Speaker 1: No, I mean, too fast would lead to malabsorption and
• 25:18
  Speaker 1: you know, you want to digest your food. Like that's
• 25:21
  Speaker 1: part of, that's everything, right?
• 25:23
  Speaker 2: Guess what you're using it for.
• 25:26
  Speaker 1: You know, if you read online, people say, oh, transit
• 25:29
  Speaker 1: time within this normal 10 to 75 hour range has
• 25:32
  Speaker 1: not been sort of associated with any particularly bad outcomes.
• 25:36
  Speaker 1: So it's nothing you need to worry about much. But
• 25:40
  Speaker 1: when we get into like the microbiology of poop, like
• 25:44
  Speaker 1: the different types of bacteria are in there, what we
• 25:47
  Speaker 1: find is actually a lot of that variation is driven
• 25:50
  Speaker 1: by transit time. So I'm going to table that for
• 25:53
  Speaker 1: a minute so that when we talk about the fecal microbiome,
• 25:57
  Speaker 1: we can remember that transit time is a thing. And
• 26:00
  Speaker 1: maybe knowing your transit time, maybe, yeah, it doesn't give
• 26:03
  Speaker 1: you any life goal in terms of making it shorter
• 26:06
  Speaker 1: or longer or whatever, but it's nevertheless interesting information from
• 26:10
  Speaker 1: sort of a scientific and physiologic standpoint. And it's fun.
• 26:13
  Speaker 3: Okay, before we get into all of that, I think
• 26:16
  Speaker 3: it's worth saying, what are the things that would make
• 26:18
  Speaker 3: you worry about your poop? Like, what are the things
• 26:21
  Speaker 3: to be concerned about if it's not transit times or frequency?
• 26:26
  Speaker 2: So one is if there is blood. Blood in the.
• 26:28
  Speaker 3: Stool always deserves a call to your doctor. I will
• 26:32
  Speaker 3: say that.
• 26:34
  Speaker 2: Fun fact, about 40% of serious.
• 26:38
  Speaker 2: Runners have blood in their stool sometimes.
• 26:41
  Speaker 3: It's very, very common after like a hard effort, after
• 26:45
  Speaker 3: a marathon.
• 26:45
  Speaker 2: Yeah.
• 26:46
  Speaker 3: Because when you're working really hard for a long period
• 26:49
  Speaker 3: of time, your body basically pulls like Everything it can
• 26:52
  Speaker 3: out of the gut, like your digestion just totally flakes apart.
• 26:56
  Speaker 1: Okay.
• 26:57
  Speaker 3: And then you have bloody diarrhea after. And it is
• 27:01
  Speaker 3: bright red blood, like just looks like what you'd be
• 27:05
  Speaker 3: very worried about.
• 27:06
  Speaker 1: Okay. Can we do an episode on like people, humans
• 27:09
  Speaker 1: shouldn't run marathons. This is, I'm going to, hot take.
• 27:13
  Speaker 1: The first guy who did it died. Died.
• 27:16
  Speaker 2: It's true.
• 27:17
  Speaker 3: But he wasn't fueling adequately. So I think that's something
• 27:20
  Speaker 3: to think about. What with the new carb options? Anyway,
• 27:24
  Speaker 3: different episode. But I will say, even if you are
• 27:27
  Speaker 3: a serious runner, if you are pooping blood, you should
• 27:31
  Speaker 3: tell your doctor about that and you can decide what
• 27:33
  Speaker 3: to do.
• 27:34
  Speaker 2: Okay.
• 27:35
  Speaker 3: Your poop shouldn't be black unless you are taking a
• 27:37
  Speaker 3: lot of iron, which will turn it black. And it
• 27:39
  Speaker 3: shouldn't be pale. That can be a sign of a
• 27:41
  Speaker 3: problem with your gallbladder.
• 27:43
  Speaker 6: Yeah.
• 27:43
  Speaker 1: I mean, pale poop is pretty scary. Gallbladder obstruction, which
• 27:48
  Speaker 1: could hopefully be a gallstone in the common bile duct,
• 27:51
  Speaker 1: but more ominously could be a sign of cancer that's
• 27:53
  Speaker 1: obstructing the common bile duct, which we don't love. So
• 27:56
  Speaker 1: definitely get that checked out.
• 27:58
  Speaker 3: The other thing is just weight loss and unexplained changes
• 28:01
  Speaker 3: in pooping. Those are potential symptoms of a serious issue.
• 28:05
  Speaker 2: And people generally should not routinely poop at night.
• 28:09
  Speaker 3: So in the middle of the night pooping, sometimes it happens,
• 28:13
  Speaker 3: but it's not a typical way your body would digest.
• 28:16
  Speaker 2: And if that's a regular thing, that's also worth a call.
• 28:20
  Speaker 1: Yeah. We talked about this in a prior episode, but
• 28:23
  Speaker 1: I think that pooping is this amazing example of the
• 28:26
  Speaker 1: brain-gut axis because your social environment cues you to poop.
• 28:34
  Speaker 1: We've talked about how for a lot of people, it's like,
• 28:39
  Speaker 1: They don't feel like they've got to go. And then
• 28:41
  Speaker 1: they get home where it's like, ooh, my nice toilet
• 28:43
  Speaker 1: and everything. And then it's like, oh, now I have
• 28:44
  Speaker 1: to go, right? Like that's your brain telling your gut, like,
• 28:46
  Speaker 1: let's go. Now's the time. Coffee does this too. So
• 28:50
  Speaker 1: caffeine obviously can stimulate your colon, but actually decaffeinated coffee
• 28:53
  Speaker 1: prompts people to poop as well. And that's probably just
• 28:57
  Speaker 1: a learned behavior. And your brain talks to your gut,
• 29:01
  Speaker 1: which is why sleeping you generally, like your brain knows
• 29:04
  Speaker 1: that it's not, you shouldn't be pooping in your sleep.
• 29:06
  Speaker 1: So if you are, talk to a doctor.
• 29:09
  Speaker 3: OK, so that is what your poop tells you on
• 29:12
  Speaker 3: a basic like what you can observe in the toilet.
• 29:15
  Speaker 3: The two other big pooping questions for me are what
• 29:19
  Speaker 3: can change your poop. So if you do find yourself
• 29:21
  Speaker 3: in a bad part of the Bristol stool scale, like
• 29:24
  Speaker 3: in the rabbit poop era of your Bristol stool, like
• 29:27
  Speaker 3: what can you do to fix it? And then I
• 29:29
  Speaker 3: want to talk about the microbiome because it's very hot
• 29:32
  Speaker 3: right now and people are totally into it and they
• 29:33
  Speaker 3: want to know about it.
• 29:35
  Speaker 2: So we're going to do both of those things. But
• 29:36
  Speaker 2: before that, let's take a quick break. Okay, we're back.
• 29:44
  Speaker 2: And I want to talk about fiber maxing. Perry, are
• 29:48
  Speaker 2: you fiber maxing?
• 29:49
  Speaker 4: Oh, so.
• 29:52
  Speaker 2: No.
• 29:54
  Speaker 1: We already did protein maxing. I'm too focused on protein
• 29:56
  Speaker 1: to focus on fiber.
• 29:57
  Speaker 2: No, sorry. You got to do both. You got to
• 29:59
  Speaker 2: do both.
• 29:59
  Speaker 3: And none of them are in this like cheese powder
• 30:02
  Speaker 3: that you eat all the time.
• 30:03
  Speaker 2: So you're in trouble.
• 30:04
  Speaker 1: I had my– do I have it here?
• 30:06
  Speaker 3: No.
• 30:06
  Speaker 1: I had my protein drink, my like Oikos 30 grams
• 30:10
  Speaker 1: of protein whey protein milkshake, which has no fiber. I'm
• 30:13
  Speaker 1: actually concerned about our lack of fiber given our protein
• 30:16
  Speaker 1: maxing stuff. Emily– I have no evidence that this is true,
• 30:21
  Speaker 1: but I'm going to assert it without evidence. Only here
• 30:24
  Speaker 1: on the Wellness Actually podcast will you hear the hosts
• 30:26
  Speaker 1: admit that they're asserting something completely without evidence. But I
• 30:30
  Speaker 1: believe that fiber, I have some evidence for this, fiber
• 30:35
  Speaker 1: might be the nutrient that Americans are sub-therapeutic, like missing
• 30:42
  Speaker 1: the recommended value on more than any other nutrient, right?
• 30:49
  Speaker 1: we talked about protein and the recommended protein intake, which
• 30:53
  Speaker 1: is quite low because it's just the amount you need
• 30:55
  Speaker 1: not to waste away to nothing. Almost every American is
• 30:57
  Speaker 1: getting more than that. And then we argued that probably
• 30:59
  Speaker 1: they should be getting more. But even the recommended amount
• 31:02
  Speaker 1: of fiber, which is like 20 to 25 grams a day,
• 31:06
  Speaker 1: according to NHANES, the mean US fiber intake is 17
• 31:11
  Speaker 1: grams a day. So like Most Americans are below, actually,
• 31:16
  Speaker 1: the recommended fiber intake. So we're bad at this, at
• 31:19
  Speaker 1: fiber maxing.
• 31:20
  Speaker 3: I don't find that very surprising, actually, because it's not
• 31:24
  Speaker 3: that easy to add fiber to stuff. Most of the
• 31:28
  Speaker 3: things we do in processing food take fiber out of it.
• 31:34
  Speaker 3: And just putting it back in is not as easy
• 31:37
  Speaker 3: as just making stuff with protein, I think.
• 31:40
  Speaker 1: Oh my God, what a good definition for ultra processed foods.
• 31:43
  Speaker 1: Not the like official definition by any stretch, but like
• 31:47
  Speaker 1: taking the fiber out to make everything easier to eat
• 31:50
  Speaker 1: and digest.
• 31:51
  Speaker 2: Yeah, high energy, Anthony.
• 31:52
  Speaker 3: But fiber comes actually in two types. It comes in
• 31:55
  Speaker 3: soluble and insoluble fiber and also fermentable and not. So
• 31:59
  Speaker 3: I guess there's like a two by two box of this.
• 32:03
  Speaker 3: So soluble fiber is like it gels.
• 32:06
  Speaker 1: It's like oatmeal.
• 32:07
  Speaker 3: Like gels things together in your stomach and it slows
• 32:10
  Speaker 3: the process of things through your, through your gut.
• 32:14
  Speaker 2: Insoluble fiber is like.
• 32:17
  Speaker 3: Like a wheat bran and, or, you know, any kind
• 32:20
  Speaker 3: of like a husk, any type of husk of things.
• 32:24
  Speaker 3: And that's like nature's broom. I think that's what people
• 32:26
  Speaker 3: think about more. It's sort of like flushes it all out.
• 32:30
  Speaker 3: And that's the stuff you see in whole form in
• 32:33
  Speaker 3: your poop a lot of the time.
• 32:35
  Speaker 1: Yeah. And this explains why doctors will recommend fiber both
• 32:38
  Speaker 1: for constipation and for diarrhea. And they'll often not go
• 32:43
  Speaker 1: into detail about like which fiber they're talking about, but
• 32:45
  Speaker 1: it's that insoluble fiber, you know, cellulose, weep ran and
• 32:49
  Speaker 1: stuff like that, that is just going to transit right through.
• 32:52
  Speaker 1: Those are non-fermenting, which means they don't cause gas formation,
• 32:55
  Speaker 1: which a lot of people don't like when they are
• 32:58
  Speaker 1: taking in fiber, right? So like looking for a non-fermentable
• 33:02
  Speaker 1: insoluble fiber is kind of going to clean you out
• 33:05
  Speaker 1: without causing too much gas. That's good for constipation. A
• 33:08
  Speaker 1: soluble non-fermenting fiber is actually going to slow things down.
• 33:12
  Speaker 1: So when you're having kind of loose stools and you
• 33:14
  Speaker 1: want to bulk up your stools, that's something like psyllium
• 33:16
  Speaker 1: would be a prototypical supplement there that doesn't cause gas.
• 33:20
  Speaker 1: And then we have all the fermentable fibers like resistant
• 33:24
  Speaker 1: starch and all the things on the FODMAP diet that
• 33:27
  Speaker 1: we talked about a few episodes ago, which are which
• 33:31
  Speaker 1: are good sources of fiber, but the bacteria in your
• 33:34
  Speaker 1: gut will ferment them and that generates gas. And then
• 33:36
  Speaker 1: you have farts, which maybe that can be our next episode.
• 33:39
  Speaker 1: Just like, let's keep going. What's the deal with farting?
• 33:44
  Speaker 2: What's the deal?
• 33:46
  Speaker 3: Good sources of fiber include beans. Beans have a lot
• 33:50
  Speaker 3: of fiber. Chia seeds have a lot of fiber. Oatmeal
• 33:52
  Speaker 3: has a good amount of soluble fiber. So there are
• 33:58
  Speaker 3: a lot of ways to get fiber, but They mostly
• 34:01
  Speaker 3: are in the form of whole foods and fruits and vegetables.
• 34:05
  Speaker 4: Yeah.
• 34:05
  Speaker 1: You got to eat your fruits and vegetables, kids. You
• 34:09
  Speaker 1: see a lot of health claims about the benefits of
• 34:10
  Speaker 1: fiber beyond like it'll keep you regular. And I think
• 34:14
  Speaker 1: there's a fair amount of support for this. I anticipate
• 34:17
  Speaker 1: Emily is not going to be as gung-ho as I am,
• 34:21
  Speaker 1: but she's already rolling her eyes. All right.
• 34:23
  Speaker 2: All right.
• 34:25
  Speaker 1: I have strong observational data from multiple studies that higher
• 34:29
  Speaker 1: fiber intake can reduce the risk of cardiovascular disease and
• 34:32
  Speaker 1: stroke as well as reduce... I'm using causal language, which
• 34:37
  Speaker 1: you're going to yell at me for. Higher fiber intake
• 34:40
  Speaker 1: is associated with a lower risk of colon cancer as well. Emily,
• 34:49
  Speaker 1: you're going to say, I predict that, well, people who
• 34:51
  Speaker 1: eat a lot of fiber do a lot of other
• 34:53
  Speaker 1: healthy things, and that's why they are... healthier in the
• 34:57
  Speaker 1: long term.
• 34:57
  Speaker 2: That's what I'm going to say.
• 34:58
  Speaker 3: And randomized trial data has actually not supported some of
• 35:01
  Speaker 3: these colon cancer claims.
• 35:03
  Speaker 1: That's a very hard trial to do because we're talking
• 35:05
  Speaker 1: about fiber intake for 20 years.
• 35:07
  Speaker 3: I agree. I agree this is a hard question to answer.
• 35:10
  Speaker 3: And I think part of my issue with this literature
• 35:13
  Speaker 3: is people say, oh, this is such a strong set
• 35:16
  Speaker 3: of things because we have this Lancet paper and it's
• 35:20
  Speaker 3: 135 million person years. But the thing is that when
• 35:24
  Speaker 3: you add data, but it has all of the same biases.
• 35:29
  Speaker 3: You haven't fixed your causal versus correlation problem. You've just
• 35:33
  Speaker 3: made your correlations more precise. It's very, very clear that
• 35:38
  Speaker 3: more fiber is associated with good health outcomes, but that
• 35:42
  Speaker 3: is very different from saying that it is a causal link.
• 35:46
  Speaker 2: And I don't think the causal evidence there is especially...
• 35:49
  Speaker 2: good and.
• 35:50
  Speaker 3: We don't need to revisit my feelings on this in
• 35:52
  Speaker 3: every episode, although we should because.
• 35:54
  Speaker 1: People are confused. I like it. It makes me feel
• 35:56
  Speaker 1: like I'm coming home to a nice warm sofa.
• 36:00
  Speaker 3: There's not even any Mendelian randomization in this one.
• 36:03
  Speaker 1: Well, if there was, I would use causal language.
• 36:05
  Speaker 5: Bummer.
• 36:05
  Speaker 1: Bummer.
• 36:08
  Speaker 3: The last thing I wanted to say about fiber is
• 36:10
  Speaker 3: that you actually do need hydration to make your poop
• 36:14
  Speaker 3: work with your fiber, but more hydration isn't more helpful.
• 36:18
  Speaker 3: So fiber tends to be like when you add it,
• 36:21
  Speaker 3: your poop gets better. You need to be adequately hydrated
• 36:24
  Speaker 3: to appropriately poop because as your poop moves through your colon,
• 36:26
  Speaker 3: it's it like pulls water out. And if you don't
• 36:29
  Speaker 3: have enough water, it will like prioritize pulling the water
• 36:32
  Speaker 3: out for other bodily functions and then leave your poop
• 36:35
  Speaker 3: all dry and bristle type one rabbit pellets. But just
• 36:40
  Speaker 3: drinking and drinking and drinking and drinking and being like
• 36:42
  Speaker 3: way more hydrated than you need to be is not
• 36:44
  Speaker 3: going to make your poop nice.
• 36:47
  Speaker 1: All right. Get my water bottle with me.
• 36:49
  Speaker 2: All right.
• 36:50
  Speaker 4: Wait.
• 36:50
  Speaker 2: I want to say two more things about how people
• 36:53
  Speaker 2: poop good.
• 36:54
  Speaker 1: Oh, yeah, yeah, yeah. Besides fiber. There's more than fiber.
• 36:56
  Speaker 2: There's more than fiber. One thing is the squatty potty.
• 36:59
  Speaker 2: Do you have a squatty potty?
• 37:01
  Speaker 1: No, I don't.
• 37:02
  Speaker 2: Oh, my God.
• 37:03
  Speaker 1: You're missing.
• 37:03
  Speaker 2: What is wrong with you?
• 37:04
  Speaker 4: I know.
• 37:05
  Speaker 1: Well, I didn't know the data, and then I did
• 37:07
  Speaker 1: the research, and now I'm like, I don't know. Squatty potty.
• 37:11
  Speaker 1: Tell me about it.
• 37:11
  Speaker 3: Squatty potty is great. So the squatty potty is just
• 37:15
  Speaker 3: a thing that you put under. It's like a plastic stool,
• 37:18
  Speaker 3: and you put it around the toilet and you put
• 37:21
  Speaker 3: your feet up on it and it changes like your posture.
• 37:23
  Speaker 3: It basically puts your knees up and it makes.
• 37:28
  Speaker 2: Your colon like, I don't know, straighter or whatever.
• 37:31
  Speaker 3: It's more mimicking a like squatting posture, which is the
• 37:34
  Speaker 3: way people pooped before we got toilets. And there's randomized data,
• 37:39
  Speaker 3: actually randomized crossover data, where they have people poop in
• 37:43
  Speaker 3: both ways. And this improves the sense of complete emptying
• 37:49
  Speaker 3: by like three times. And it reduces the straining by
• 37:53
  Speaker 3: a lot. And this is very cheap. And the effect
• 37:57
  Speaker 3: sizes are big. And I really, really think that you
• 38:00
  Speaker 3: should get one.
• 38:02
  Speaker 1: Do you have one?
• 38:04
  Speaker 2: Absolutely. We have multiple. I have them on like all
• 38:06
  Speaker 2: of my toilets. I'm not an idiot. Yes.
• 38:10
  Speaker 1: I'm an idiot. I want to file this. So, okay.
• 38:17
  Speaker 1: So I was seeing some crazy stuff online of, okay,
• 38:19
  Speaker 1: this is gross, but people being like, if you're really
• 38:21
  Speaker 1: poop maxing, you shouldn't have to wipe. Okay. Like, and
• 38:25
  Speaker 1: that's gross, first of all.
• 38:26
  Speaker 2: That's gross.
• 38:28
  Speaker 1: But one of the arguments is like, animals don't wipe. Right.
• 38:32
  Speaker 1: That is true.
• 38:33
  Speaker 2: It's not the most compelling.
• 38:35
  Speaker 3: I used to have this cat that didn't wipe and
• 38:37
  Speaker 3: it always had poop all over its butt. So like
• 38:39
  Speaker 3: I'm just like not getting into this.
• 38:42
  Speaker 1: One of the things though– so like why I do
• 38:45
  Speaker 1: these deep dives for this podcast, I don't know. It
• 38:48
  Speaker 1: shows that something is deeply wrong with me. But I
• 38:50
  Speaker 1: went to a little bit of evolutionary biology and it
• 38:52
  Speaker 1: turns out that– One of the reasons we have to
• 38:56
  Speaker 1: wipe is because we walk erect. It's like we can
• 38:59
  Speaker 1: add it to the checklist of things that because we
• 39:02
  Speaker 1: evolved to walk erect, which gave us use of our
• 39:04
  Speaker 1: hands for tools, that was very nice. And maybe like
• 39:07
  Speaker 1: seeing over some high grasses in the African Savannah or
• 39:09
  Speaker 1: whatever else it was, we condemned ourselves to like a
• 39:13
  Speaker 1: life of back pain. A birth canal that is all
• 39:17
  Speaker 1: jacked up and high maternal mortality and the need to
• 39:20
  Speaker 1: wipe our poops. And apparently there's evidence that humans have
• 39:26
  Speaker 1: been wiping their poops since like before civilization, before we
• 39:30
  Speaker 1: had paper, before we had anything. So it's not like
• 39:33
  Speaker 1: that animals are doing something right and we're doing something wrong.
• 39:36
  Speaker 1: It's we should never have stood up in the first place.
• 39:40
  Speaker 1: And maybe the squatty potty corrects that just a little bit.
• 39:43
  Speaker 2: I'm not really sure that's what the squatty potty does.
• 39:45
  Speaker 3: And you still have to you still have to keep
• 39:48
  Speaker 3: wiping people. You keep wiping. People don't stop wiping. I
• 39:53
  Speaker 3: do have one.
• 39:54
  Speaker 1: Of those bidet-like seats on my toilet, which is a
• 39:59
  Speaker 1: total game changer, I will say.
• 40:01
  Speaker 4: I love it. Okay.
• 40:02
  Speaker 2: It's nice.
• 40:03
  Speaker 3: The other thing is you should not use your phone
• 40:07
  Speaker 3: on the toilet. Because it encourages you to sit for
• 40:10
  Speaker 3: too long.
• 40:10
  Speaker 1: That is insane. And then you get hemorrhoids. You're crazy.
• 40:15
  Speaker 3: I realize this is a stupid thing to say. And
• 40:17
  Speaker 3: many of us use our phone on the toilet all
• 40:19
  Speaker 3: the time.
• 40:19
  Speaker 2: And I don't.
• 40:21
  Speaker 3: But it is, I think a different way to say
• 40:23
  Speaker 3: this is there have been some studies associated with that
• 40:27
  Speaker 3: show that people use their phone, you just sit for
• 40:29
  Speaker 3: too long. So using your phone briefly on the toilet
• 40:31
  Speaker 3: is fine. But if you're just like sitting and sitting
• 40:33
  Speaker 3: because you're trying to avoid your family and scrolling on
• 40:35
  Speaker 3: your phone.
• 40:36
  Speaker 2: On the toilet.
• 40:37
  Speaker 3: You should get off the toilet and sit in a
• 40:38
  Speaker 3: different part of the bathroom and pretend that you're on
• 40:40
  Speaker 3: the toilet because otherwise you're going to get hemorrhoids.
• 40:44
  Speaker 1: Yeah, I saw that study and I think it's right,
• 40:46
  Speaker 1: but it is very hard. I will say if I
• 40:47
  Speaker 1: like forget my phone, like if I leave my phone
• 40:49
  Speaker 1: in another room and I'm on the toilet, I am desperate.
• 40:53
  Speaker 1: Like I will grab a shampoo bottle and read the ingredients.
• 40:57
  Speaker 2: You can't be alone with yourself. What does that tell us, Barry?
• 41:01
  Speaker 1: I cannot do it. I can't just sit quietly with
• 41:05
  Speaker 1: my thoughts.
• 41:05
  Speaker 2: Or For like the 12 seconds that it should take you. Actually,
• 41:10
  Speaker 2: you know what would be better? If you got a
• 41:11
  Speaker 2: squatty potty, you'd be going faster and then you wouldn't
• 41:13
  Speaker 2: be so bored.
• 41:15
  Speaker 4: All right.
• 41:15
  Speaker 1: Squatty potty, hook me up.
• 41:18
  Speaker 2: Okay.
• 41:19
  Speaker 3: So knees up, phones down, eat your fiber, drink some water,
• 41:26
  Speaker 3: have some coffee.
• 41:27
  Speaker 2: That's like the practical stuff.
• 41:29
  Speaker 3: But the More like fun, sexy piece of this is
• 41:34
  Speaker 3: the microbiome and the idea that this exciting constellation of
• 41:40
  Speaker 3: bacteria and fungi that are living in us are really
• 41:44
  Speaker 3: important for a lot of things. I feel like the
• 41:47
  Speaker 3: microbiome had like a big moment like a couple of
• 41:49
  Speaker 3: years ago. And now I kind of like every episode
• 41:52
  Speaker 3: of The Economist had a thing about the microbiome.
• 41:54
  Speaker 2: I feel like it's like died out a little bit.
• 41:56
  Speaker 1: Oh, in the medical side, it's still like.
• 41:58
  Speaker 2: Oh, you guys are still really into it. Oh, yeah.
• 42:00
  Speaker 1: Okay, great.
• 42:01
  Speaker 4: Excellent.
• 42:02
  Speaker 2: So what is this and why are we thinking about it?
• 42:05
  Speaker 2: Why do we care? Okay.
• 42:07
  Speaker 1: So everyone knows there's bacteria in your stool, but it's
• 42:13
  Speaker 1: more than just there's bacteria. It is an ecosystem. There
• 42:18
  Speaker 1: are thousands of types of different species of bacteria that
• 42:25
  Speaker 1: live in your gut, that live in your colon. They're
• 42:28
  Speaker 1: all interacting with each other. They're digesting food for you.
• 42:31
  Speaker 1: They're releasing substances that are absorbed into your body. Without them,
• 42:34
  Speaker 1: we would be very sick. These are symbiotes that live
• 42:39
  Speaker 1: within us. People often ask, like you'll hear statistics like
• 42:44
  Speaker 1: how much bacteria do you have in your colon with like,
• 42:46
  Speaker 1: I have 10 pounds of bacteria. That's not true. You
• 42:48
  Speaker 1: have 0.2 kilograms worth of bacteria in your colon. That's
• 42:51
  Speaker 1: about an apple's worth of bacteria. But that's still a
• 42:54
  Speaker 1: lot because bacteria are very small. So the way most
• 43:00
  Speaker 1: microbiome studies work is you take a stool sample that
• 43:04
  Speaker 1: is sent to to a lab under varying conditions. There
• 43:07
  Speaker 1: are some problems with these studies, and it's mixed up.
• 43:10
  Speaker 1: And labs will do DNA sequencing for a bunch of
• 43:13
  Speaker 1: different known bacteria. So every bacteria has a short sequence
• 43:18
  Speaker 1: of DNA that's kind of unique to it. And it's
• 43:19
  Speaker 1: just like, OK, if we find this sequence of DNA,
• 43:22
  Speaker 1: we can therefore infer that this particular bacteria was in
• 43:25
  Speaker 1: the stool. And you do that for a bunch of
• 43:27
  Speaker 1: different hundreds or even thousands of different bacteria. And you
• 43:29
  Speaker 1: can see the relative amounts of bacteria in someone's stool.
• 43:34
  Speaker 1: And basically, everyone has about 14 genuses. They're the same
• 43:40
  Speaker 1: 14 genuses of bacteria. That's sort of like the human
• 43:44
  Speaker 1: stool microbiome. But that vastly underestimates the amount of diversity
• 43:50
  Speaker 1: from person to person. So in a study of 4,000 people,
• 43:55
  Speaker 1: looking at their stool microbiome, 75%, so 3,000 of those
• 43:59
  Speaker 1: 4,000 had at least one bacteria type that was not
• 44:04
  Speaker 1: found in any other person. So the chances are you
• 44:08
  Speaker 1: have a bacteria living in your colon that at least
• 44:11
  Speaker 1: in your town, there is no one else who has
• 44:15
  Speaker 1: that particular bacteria. And that seems nice.
• 44:19
  Speaker 2: That's super cool.
• 44:20
  Speaker 1: Is that nice? I feel like I would want to
• 44:22
  Speaker 1: know my personal bacteria a little bit better and like
• 44:26
  Speaker 1: talk to it, see how it's like in life.
• 44:28
  Speaker 3: So people's microbiome is in that sense quite person specific.
• 44:34
  Speaker 3: So actually like you can identify even a year later,
• 44:38
  Speaker 3: people have shown like you can basically re-identify like 80%
• 44:41
  Speaker 3: of people a year later by various like aspects of
• 44:47
  Speaker 3: their microbiome. Having said that, there's actually quite a lot
• 44:50
  Speaker 3: of individual over time variation within an individual in your microbiome.
• 44:54
  Speaker 3: So it's not like you have one kind and exactly
• 44:58
  Speaker 3: the same number of bacteria all the time. It's moving
• 45:00
  Speaker 3: around with various aspects of your life.
• 45:03
  Speaker 1: It's moving around a ton. And I don't think people
• 45:06
  Speaker 1: appreciate the amount of within-person variation. So for example, a
• 45:11
  Speaker 1: lot of the wellness microbiome... influencers will talk about certain
• 45:16
  Speaker 1: species of bacteria and the relative abundance of something like
• 45:20
  Speaker 1: acromantia or whatever. Your acromantia is too low. You need
• 45:22
  Speaker 1: to take this supplement that I happen to sell to
• 45:24
  Speaker 1: boost your acromantia. And any individual bacteria might vary in
• 45:30
  Speaker 1: terms of concentration by tenfold between one day and the
• 45:34
  Speaker 1: next day. So it's very different saying, taking the entire
• 45:39
  Speaker 1: sum of bacteria we can re-identify you from a data set,
• 45:42
  Speaker 1: sort of like, oh, everyone has kind of unique fingerprints,
• 45:46
  Speaker 1: than to say, oh, the particular whorls on your fingerprint
• 45:51
  Speaker 1: are causing health or disease, right? The fact that many
• 45:56
  Speaker 1: people are surprised at is there is no reference microbiome.
• 46:00
  Speaker 2: There's no good yet. I mean, this is the thing
• 46:02
  Speaker 2: about this.
• 46:02
  Speaker 4: There's no normal.
• 46:02
  Speaker 2: People are like, make your microbiome great. By what? How
• 46:07
  Speaker 2: would I know if it was great?
• 46:09
  Speaker 1: Who is the guy? Who are we aspiring to be?
• 46:11
  Speaker 2: Who's the person with the best microbiome? What is Brian Johnson?
• 46:15
  Speaker 3: I mean, we probably do know what Brian Johnson's microbiome is,
• 46:17
  Speaker 3: but is that something to aspire to?
• 46:20
  Speaker 2: I don't know.
• 46:22
  Speaker 3: There is no optimal here the way there might be
• 46:24
  Speaker 3: in some other things that we might measure.
• 46:29
  Speaker 1: Yeah, micro, what's his name? Brian Johnson's microbiome is probably
• 46:33
  Speaker 1: screwed up because he has autoimmune gastritis. So I don't
• 46:37
  Speaker 1: think I want his microbiome. Yeah, so these things are
• 46:40
  Speaker 1: shifting around a lot. It is unique to you. The
• 46:42
  Speaker 1: primary driver, I mean, you know, people will tell you, oh, it's,
• 46:46
  Speaker 1: you know, what you're eating and your health lifestyle behaviors,
• 46:49
  Speaker 1: it's going to change your flora and your fauna inside
• 46:53
  Speaker 1: your gut. The primary driver in all of these studies
• 46:56
  Speaker 1: that does repeat testing, right? So the same person, like
• 46:59
  Speaker 1: what is causing change here is, callback, transit time. That
• 47:04
  Speaker 1: seems to be the thing that changes your microbiome. And
• 47:07
  Speaker 1: that makes biologic sense because the longer stool is sitting
• 47:12
  Speaker 1: in there, right? the more oxygen is getting taken up
• 47:15
  Speaker 1: by aerobic bacteria. So the oxygen levels are going down.
• 47:19
  Speaker 1: And then the anaerobic bacteria, the bacteria that don't need
• 47:22
  Speaker 1: oxygen to grow, start growing sort of later in the process.
• 47:26
  Speaker 1: And so there's these dynamic shifts. There is some associational
• 47:31
  Speaker 1: data that a greater percentage of anaerobic bacteria are associated
• 47:37
  Speaker 1: with some worse health outcomes than aerobic bacteria that might
• 47:43
  Speaker 1: argue that shorter transit times would be better, or maybe
• 47:48
  Speaker 1: it argues that having a diet that promotes short transit
• 47:52
  Speaker 1: times is healthy.
• 47:54
  Speaker 2: Because it has a lot of fiber in it.
• 47:56
  Speaker 1: Right. And the bacteria are just sort of like a
• 47:58
  Speaker 1: side effect that are kind of moving around based on
• 48:01
  Speaker 1: that exposure.
• 48:02
  Speaker 3: So this for me is like the core issue with
• 48:05
  Speaker 3: this microbiome stuff, which is like it is crystal clear
• 48:09
  Speaker 3: that the microbiome varies across people.
• 48:12
  Speaker 2: And that it plays a role in our lives, right?
• 48:15
  Speaker 3: And we can, I'm going to talk about this in
• 48:16
  Speaker 3: a second, but like, you know, getting rid of your
• 48:18
  Speaker 3: microbiome would be an extremely bad idea.
• 48:21
  Speaker 2: We definitely are using that.
• 48:23
  Speaker 3: But that is totally different from saying like, this is
• 48:27
  Speaker 3: a thing where changing it, even if you know how
• 48:32
  Speaker 3: to do that, would necessarily have some positive health outcome
• 48:35
  Speaker 3: or knowing that in more detail, like how would I
• 48:38
  Speaker 3: change it and what would I want to achieve? And
• 48:41
  Speaker 3: that could be different for different people.
• 48:42
  Speaker 2: That's the other thing.
• 48:43
  Speaker 3: It could be like my optimal microbiome is different from
• 48:45
  Speaker 3: your optimal microbiome.
• 48:48
  Speaker 1: Totally. That's true. Yeah. We know that. Well, do we
• 48:51
  Speaker 1: know that? I guess we don't know what an optimal
• 48:53
  Speaker 1: microbiome is, so I don't know. But I even want
• 48:55
  Speaker 1: to hammer home one more time that we don't really
• 48:57
  Speaker 1: know whether the readout of bacteria in your poop is
• 49:02
  Speaker 1: a result of your health or- that the bacteria in
• 49:07
  Speaker 1: your poop are causing health changes. So for example, like
• 49:12
  Speaker 1: let's just talk about what you'll hear when it comes
• 49:14
  Speaker 1: to microbiome. So you'll hear that there's a, I'll sometimes
• 49:17
  Speaker 1: call it a dysbiosis pattern, right? So no researcher worth
• 49:21
  Speaker 1: their salt is going to tell you that any one
• 49:23
  Speaker 1: type of bacteria in your stool is good or bad.
• 49:25
  Speaker 1: I mean, obviously if you have like salmonella, that's bad,
• 49:27
  Speaker 1: but you know what I mean? Like they're not going
• 49:28
  Speaker 1: to tell you that like, oh, this particular, you want
• 49:31
  Speaker 1: this higher, this lower, whatever, but they will use very
• 49:35
  Speaker 1: complicated statistical techniques to identify patterns of And they have
• 49:38
  Speaker 1: found patterns that are associated with things like inflammatory bowel disease,
• 49:43
  Speaker 1: colon cancer, obesity, and other metabolic diseases. To me, a
• 49:50
  Speaker 1: common thread in this dysbiosis pattern is that inflammation in
• 49:55
  Speaker 1: the colon leads to decreased oxygen tension, which leads to
• 49:59
  Speaker 1: increased anaerobic bacteria. So I can tell a story where
• 50:03
  Speaker 1: you have inflammatory bowel disease for some other reason, cause inflammation.
• 50:08
  Speaker 1: That inflammation changes your gut bacteria. We read that out
• 50:10
  Speaker 1: of your poop. Fine. Gut bacteria, nothing to do with it.
• 50:13
  Speaker 1: They're just, they are enjoying the environment in which they live,
• 50:16
  Speaker 1: the anaerobic environment in which they live. Here's another story
• 50:18
  Speaker 1: that's consistent with that data. For whatever reason, you got
• 50:21
  Speaker 1: colonized with more anaerobic bacteria because, I don't know, you've
• 50:24
  Speaker 1: eaten wrong and you didn't get your, you know, enough
• 50:27
  Speaker 1: fiber or whatever. Those bacteria release substances that angry up
• 50:32
  Speaker 1: your colon, which then becomes inflamed and gives you inflammatory
• 50:35
  Speaker 1: bowel disease. That's the state of observational data right now.
• 50:40
  Speaker 1: And the only way to sort of figure out causality
• 50:44
  Speaker 1: here is to do fairly dramatic things to try to
• 50:47
  Speaker 1: change the microbiome in a human and see, like, does
• 50:51
  Speaker 1: it change their health?
• 50:53
  Speaker 3: And this is a place where I think the start
• 50:57
  Speaker 3: of some of this microbiome is based on a really,
• 51:01
  Speaker 3: really compelling set of very specific data.
• 51:05
  Speaker 2: There's a condition called C.
• 51:07
  Speaker 3: Diff, which is a very debilitating diarrheal disease that people
• 51:16
  Speaker 3: can get. And it's like a recurrent, persistent infection that
• 51:21
  Speaker 3: can be really, again, sort of really terrible. And it
• 51:24
  Speaker 3: turns out that fecal transplants... transplanting healthy stool into the
• 51:32
  Speaker 3: colon of somebody who has this is incredibly effective at
• 51:36
  Speaker 3: treating this like much, much, much more effective, like 80
• 51:41
  Speaker 3: to 90% resolution versus standard antibiotics, which have a pretty
• 51:44
  Speaker 3: low effect. This is like, this is the way that
• 51:46
  Speaker 3: you treat this disease now effectively.
• 51:49
  Speaker 6: Yeah.
• 51:49
  Speaker 1: Recurrent C. diff, you know, and this makes sense because C. diff,
• 51:53
  Speaker 1: Clostridium difficile is can colonize your gut when the other
• 51:57
  Speaker 1: bacteria in your gut are killed. Most people get this
• 51:59
  Speaker 1: after taking a course of antibiotics. It's often a hospital-acquired infection.
• 52:03
  Speaker 1: You get antibiotics, that kills off all your, quote unquote,
• 52:05
  Speaker 1: good bacteria in your gut, C. diff takes over. And
• 52:08
  Speaker 1: you need to get those good bacteria back, and Healthy
• 52:11
  Speaker 1: Stool has those good bacteria in it. So yeah, fecal
• 52:14
  Speaker 1: microbiota transplant. Pretty awesome. Endorsed by every major society for
• 52:18
  Speaker 1: recurrent C.
• 52:19
  Speaker 2: Diff.
• 52:20
  Speaker 3: And This has been explored then in treatment of similar
• 52:24
  Speaker 3: things like IBS, which the evidence is a little more mixed,
• 52:27
  Speaker 3: ulcerative colitis, but places where it seems like there's something
• 52:31
  Speaker 3: going wrong in the sort of stool transit system that
• 52:35
  Speaker 3: might be impacted by changing the bacteria. All of this
• 52:41
  Speaker 3: other shit that people tell you though, this is actually
• 52:44
  Speaker 3: not supported. So there's this sort of idea like, okay, well,
• 52:46
  Speaker 3: if taking someone with a really serious illness and putting
• 52:49
  Speaker 3: somebody else's poop in them is gonna fix that illness,
• 52:52
  Speaker 3: then maybe you would just generally get healthier if you
• 52:56
  Speaker 3: took some capsules of bacteria.
• 52:59
  Speaker 2: But like, those are not the same activities at all.
• 53:04
  Speaker 1: A hundred percent. And it's that theme again, where wellness influencers-
• 53:09
  Speaker 1: start with biologic plausibility, and it's there. There is biologic
• 53:13
  Speaker 1: plausibility here. And then they just jump to, let me
• 53:16
  Speaker 1: sell you this product without any of the steps in between.
• 53:20
  Speaker 1: And when you look at those steps in between, you
• 53:23
  Speaker 1: find that that stuff doesn't work. So maybe, I mean,
• 53:28
  Speaker 1: should we talk about probiotics for a minute?
• 53:31
  Speaker 2: Yeah, let's talk about probiotics.
• 53:32
  Speaker 5: All right.
• 53:34
  Speaker 2: What do you think?
• 53:36
  Speaker 1: I will give you three things. that probiotics have been
• 53:41
  Speaker 1: definitively established to be useful for. Everyone ready?
• 53:46
  Speaker 3: All right.
• 53:46
  Speaker 1: And by the way, multi-billion dollar industry out there. So
• 53:51
  Speaker 1: huge industry. Here are the three things. Preventing Clostridium difficile
• 53:55
  Speaker 1: while you're taking antibiotics.
• 53:58
  Speaker 4: Okay. Okay.
• 54:00
  Speaker 1: Necrotizing enterocolitis in premature infants. And pouchitis, which is an
• 54:07
  Speaker 1: inflammation of the distal ileum in people who have had
• 54:10
  Speaker 1: a colectomy, and that is it. The American Gastroenterological Association
• 54:16
  Speaker 1: specifically advises against probiotics for inflammatory bowel disease, irritable bowel syndrome,
• 54:21
  Speaker 1: or kids with gastroenteritis.
• 54:24
  Speaker 2: It's disappointing.
• 54:26
  Speaker 1: Which is what everyone is using this stuff for.
• 54:28
  Speaker 4: Yeah.
• 54:29
  Speaker 3: I mean, yes, those are all the things people use
• 54:32
  Speaker 3: it for.
• 54:33
  Speaker 1: Yeah.
• 54:33
  Speaker 3: I mean, There are some reasons to think that this
• 54:37
  Speaker 3: wouldn't work. So, you know, there's some reasonable evidence that
• 54:42
  Speaker 3: the probiotic for most, for many people just never colonizes,
• 54:45
  Speaker 3: like just gets sort of eaten by other bacteria.
• 54:49
  Speaker 2: The other thing is probiotics. Yeah, digest it.
• 54:52
  Speaker 3: The other thing is these probiotics are just a bunch
• 54:55
  Speaker 3: of different random stuff. And even if your problem was
• 54:59
  Speaker 3: that you were deficient in something that was causing some symptom,
• 55:04
  Speaker 3: it's not at all clear that just taking the random
• 55:06
  Speaker 3: probiotic that they sell at CVS or whatever was going
• 55:09
  Speaker 3: to fix that particular set of issues.
• 55:12
  Speaker 1: Right. It would be like someone saying, you know, you
• 55:15
  Speaker 1: should take an antibiotic for that. And it's just like, oh, okay,
• 55:19
  Speaker 1: there's a lot of different antibiotics. And then of course,
• 55:22
  Speaker 1: you know, saying that there are plenty of influencers and
• 55:25
  Speaker 1: naturopaths and people who will tell you exactly which specific
• 55:29
  Speaker 1: strain of whatever and no doubt sell it to you
• 55:33
  Speaker 1: as well. And I'll just say there's no robust data
• 55:36
  Speaker 1: for any of them.
• 55:38
  Speaker 3: You can actually pay people to test your stool and
• 55:41
  Speaker 3: then sell you the stuff that will fix it. And
• 55:44
  Speaker 3: what's so great is that when researchers have done this,
• 55:49
  Speaker 3: they actually sent this one paper where they sent the
• 55:53
  Speaker 3: same poop to a bunch of different companies and they all,
• 55:57
  Speaker 3: like a lot of them just came back saying different
• 55:59
  Speaker 3: random things.
• 56:01
  Speaker 2: Like, you know, they counted them differently wrong. Somebody said
• 56:04
  Speaker 2: it was healthy. Somebody said it was, it was unhealthy.
• 56:07
  Speaker 3: You know, companies disagree with themselves.
• 56:09
  Speaker 2: And then they're like, here's the supplement that you need
• 56:12
  Speaker 2: to fix this problem.
• 56:13
  Speaker 1: It's like, um, It sounds like a great business model.
• 56:17
  Speaker 2: It's an amazing business.
• 56:19
  Speaker 3: $ 400 to test your poop, plus you buy our supplements.
• 56:23
  Speaker 2: I'm minting money. Where do I invest in this?
• 56:29
  Speaker 4: Yeah.
• 56:29
  Speaker 1: No, I mean, this is the direct-to-consumer world, and it
• 56:33
  Speaker 1: has all the trappings of science, and it's just, it's problematic.
• 56:37
  Speaker 1: This is a very complicated area. The testing is not easy.
• 56:40
  Speaker 1: By the way, when you send poop in the mail,
• 56:42
  Speaker 1: the bacteria isn't dead.
• 56:44
  Speaker 2: Right?
• 56:44
  Speaker 1: Like it's going to continue to grow. So it'll change
• 56:48
  Speaker 1: based on the temperature that it's sent at. Not, you know,
• 56:51
  Speaker 1: a lot of these are sent at room temperature. It'll
• 56:52
  Speaker 1: change based on how long it takes to get to
• 56:55
  Speaker 1: the facility and when they're actually testing it and stuff.
• 56:57
  Speaker 1: It's just, there's no valid way to, to do this for, uh, Let.
• 57:03
  Speaker 2: Me ask you a question.
• 57:03
  Speaker 3: Do you think what share of these companies do you
• 57:06
  Speaker 3: think are just getting the poop in the mail, throwing
• 57:08
  Speaker 3: it in the trash, generating like a random set of
• 57:11
  Speaker 3: data and then telling you to.
• 57:12
  Speaker 2: Buy their supplements? You think it's like half?
• 57:14
  Speaker 1: No.
• 57:15
  Speaker 2: I don't think it's outright fraud. You're so nice.
• 57:19
  Speaker 1: Well, the testing is not, like, this is routine PCR testing. Like,
• 57:23
  Speaker 1: it's not expensive to do. It's hard to do correctly.
• 57:26
  Speaker 3: No, but it's just like you have to open up
• 57:28
  Speaker 3: these boxes of people's poop that they ship.
• 57:29
  Speaker 2: I don't know, man.
• 57:30
  Speaker 1: That feels like outright fraud to me. I don't know.
• 57:32
  Speaker 1: I like to believe in the inherent goodness of humankind.
• 57:35
  Speaker 1: Wellness grifters.
• 57:36
  Speaker 2: You like to believe in the inherent goodness of grifters.
• 57:39
  Speaker 1: Okay, that's awesome. Self-interestedness. There's one microbiome study... and this
• 57:46
  Speaker 1: is a little far afield, but I think it's such
• 57:48
  Speaker 1: interesting science that I did want to bring it up.
• 57:50
  Speaker 1: And that's the discordant twin obesity poop study. Can we
• 57:57
  Speaker 1: talk about this?
• 57:58
  Speaker 3: Yeah.
• 57:59
  Speaker 4: Yeah.
• 57:59
  Speaker 1: But in, in like, but in humans, yes, yes.
• 58:01
  Speaker 5: Yeah.
• 58:01
  Speaker 2: Talk about this.
• 58:02
  Speaker 1: This is a cool study.
• 58:03
  Speaker 2: Okay.
• 58:04
  Speaker 1: So the, this is a study that prompted people to
• 58:08
  Speaker 1: begin saying that obesity is a disease of the microbiome
• 58:12
  Speaker 1: that We can fix the obesity crisis by somehow changing
• 58:16
  Speaker 1: our microbiome. And it's a really fascinating study appearing in
• 58:18
  Speaker 1: Science in 2013. It's a very small study. Emily points
• 58:22
  Speaker 1: out it's largely in mice. But hey, it's worth talking
• 58:24
  Speaker 1: about because people mention it. So what they did is
• 58:26
  Speaker 1: they took four female twin pairs who were discordant for obesity.
• 58:32
  Speaker 1: So one of the twins had to have a BMI
• 58:35
  Speaker 1: greater than 30 and the other couldn't. And they had
• 58:37
  Speaker 1: to have at least 5.5 BMI points between them for
• 58:42
  Speaker 1: at least several years. So they were really, they were
• 58:44
  Speaker 1: like different. By the way, only one of the four
• 58:46
  Speaker 1: twin pairs were identical. The other, you know, the other three,
• 58:49
  Speaker 1: it would be very hard to find identical twins that
• 58:51
  Speaker 1: were this discordant on obesity because so much of obesity
• 58:55
  Speaker 1: is driven by genetics. So whatever. So three of the
• 58:58
  Speaker 1: pairs were, you know, dizygotic fraternal twins.
• 59:01
  Speaker 4: Okay.
• 59:01
  Speaker 1: But then what they did is they took germ-free mice.
• 59:03
  Speaker 1: So these are mice who have no bacteria. They're raised
• 59:06
  Speaker 1: in a germ-free environment. I think they're even birthed by
• 59:08
  Speaker 1: C-sections so as not to become by their mom's vaginal flora.
• 59:13
  Speaker 1: So germ-free mice. And they gave them fecal microbiota transplant
• 59:17
  Speaker 1: from each twin and let them eat whatever they wanted.
• 59:21
  Speaker 1: And the mice given the obese twin feces gained more
• 59:25
  Speaker 1: total and fat mass And developed metabolic complications associated with obesity,
• 59:30
  Speaker 1: like elevated blood sugar and things like that. Whereas the
• 59:37
  Speaker 1: mouse that received the other twins just developed like a
• 59:40
  Speaker 1: normal mouse. So sort of a compelling study to suggest
• 59:44
  Speaker 1: that something is going on with the bacteria there. Are
• 59:48
  Speaker 1: they releasing something that's encouraging more eating behavior? Are they
• 59:52
  Speaker 1: slowing the metabolism by secreting some bacterial metabolite? We don't know. Interestingly,
• 59:57
  Speaker 1: when they mixed the mice together in the same cage,
• 1:00:02
  Speaker 1: so the lean mice and the obese mice were put
• 1:00:04
  Speaker 1: in the same cage, the obese mice lost weight. And
• 1:00:07
  Speaker 1: the reason they lost weight is because they ate... Mice
• 1:00:12
  Speaker 1: eat each other's poop. That's like a mouse behavior. And
• 1:00:14
  Speaker 1: so the obese mice ate the poop of the lean mice.
• 1:00:18
  Speaker 1: And the lean mice ate the poop of the obese mice,
• 1:00:20
  Speaker 1: but apparently lean microbiome dominates and the obese... mice lost weight. Now,
• 1:00:28
  Speaker 1: I can't think of any reason that this isn't 100%
• 1:00:31
  Speaker 1: applicable to human beings.
• 1:00:34
  Speaker 6: Can you?
• 1:00:36
  Speaker 3: I can't think of anything, but it turns out the experiments,
• 1:00:39
  Speaker 3: they're difficult to recruit for.
• 1:00:41
  Speaker 2: The experiments that ended poop eating.
• 1:00:43
  Speaker 3: And so they haven't, for that reason and many others perhaps,
• 1:00:46
  Speaker 3: this is actually, they've struggled to replicate this in humans.
• 1:00:49
  Speaker 3: And so this hasn't, not for the reason I said,
• 1:00:52
  Speaker 3: but for other science reasons. So this hasn't kind of
• 1:00:55
  Speaker 3: led to some microbiome-related treatment for obesity.
• 1:00:59
  Speaker 4: It hasn't.
• 1:00:59
  Speaker 1: And there have been randomized trials of probiotics for obesity,
• 1:01:02
  Speaker 1: and they have really no effects. It doesn't seem like
• 1:01:05
  Speaker 1: that's the driver in humans.
• 1:01:07
  Speaker 2: But it is very interesting. Yeah. All right.
• 1:01:10
  Speaker 3: My big picture takeaway on the poop here is that actually,
• 1:01:15
  Speaker 3: you should be paying some attention to your poop.
• 1:01:17
  Speaker 2: If for no other reason than....
• 1:01:21
  Speaker 3: Having a nice poop every day and not being constipated
• 1:01:25
  Speaker 3: or having diarrhea really improves your life.
• 1:01:27
  Speaker 2: Yeah.
• 1:01:28
  Speaker 3: I think for most people, like that's just like, that
• 1:01:30
  Speaker 3: is a part, like if every morning you just had
• 1:01:33
  Speaker 3: one nice poop and you didn't worry about it for
• 1:01:34
  Speaker 3: the rest of the day, like that's good.
• 1:01:37
  Speaker 2: That's a good way to start your day.
• 1:01:39
  Speaker 3: And there are some ways to make that more possible,
• 1:01:41
  Speaker 3: but that is different from saying once you are at that,
• 1:01:44
  Speaker 3: you're maxed. That's the poop max. There's no further poop
• 1:01:47
  Speaker 3: maxing from there. I think that we need to be doing.
• 1:01:50
  Speaker 3: That's at least my take.
• 1:01:52
  Speaker 1: I think you could not have said that better. That's
• 1:01:56
  Speaker 1: my hashtag poop goal. And I think I'm pretty close.
• 1:02:00
  Speaker 1: I think I'm pretty close to being there. But maybe
• 1:02:03
  Speaker 1: I need to eat more fiber like every other American.
• 1:02:04
  Speaker 2: No, you need to get a squatty potty.
• 1:02:06
  Speaker 1: I don't understand.
• 1:02:07
  Speaker 2: Just get a squatty potty.
• 1:02:09
  Speaker 4: Okay.
• 1:02:09
  Speaker 1: Squatty potty coming right up.
• 1:02:12
  Speaker 2: All right.
• 1:02:12
  Speaker 1: Well, so I think I know where you're going to
• 1:02:13
  Speaker 1: be on this, Emily, but smash or pass poop.
• 1:02:17
  Speaker 2: Smash on poop. Smash on poop.
• 1:02:20
  Speaker 1: I agree. I'm thankful for poop and more importantly for
• 1:02:27
  Speaker 1: regular poops on a Bristol stool scale of three to four.
• 1:02:37
  Speaker 2: All right. That's it for poop. Your mailback question of
• 1:02:39
  Speaker 2: the week after the break.
• 1:02:45
  Speaker 1: And now for our question of the week, by the way,
• 1:02:47
  Speaker 1: if you have a question for Emily and I, reach
• 1:02:50
  Speaker 1: out to us at wellnessactually.fm. We would love to hear
• 1:02:53
  Speaker 1: from you. All right, let's play it.
• 1:02:54
  Speaker 4: Hi, Emily and Perry. This is Jamie from Boston. And
• 1:02:58
  Speaker 4: my question is about all the water that everyone is
• 1:03:00
  Speaker 4: supposed to be drinking all the time. I feel like
• 1:03:03
  Speaker 4: if I don't have my water bottle with me, I
• 1:03:05
  Speaker 4: might die of thirst. Nevermind my preschooler who always has
• 1:03:10
  Speaker 4: to have her water bottle at school. We didn't have
• 1:03:13
  Speaker 4: this in the 90s when we were drinking from those
• 1:03:15
  Speaker 4: unrefrigerated ceramic water fountains. Did water become more important? When
• 1:03:21
  Speaker 4: did that happen? Why?
• 1:03:22
  Speaker 2: Okay, thanks.
• 1:03:25
  Speaker 3: Okay, Perry, you are a kidney doctor who grew up
• 1:03:27
  Speaker 3: in the 1980s. So what is going on with the
• 1:03:32
  Speaker 3: excessive hydration that's occurring now?
• 1:03:34
  Speaker 1: You're not going to like what I say. Drink more
• 1:03:38
  Speaker 1: water is such an easy... bit of wellness advice, especially
• 1:03:44
  Speaker 1: living in a country with robust access to healthy water
• 1:03:48
  Speaker 1: supplies and with good water bottles. The truth is that
• 1:03:55
  Speaker 1: most people get a totally adequate amount of water. So physiologically,
• 1:03:59
  Speaker 1: I know, I know, no one's happy. Everyone's upset. Okay, listen. Physiologically,
• 1:04:05
  Speaker 1: thirst is one of the most powerful sensations that animals have.
• 1:04:12
  Speaker 1: We become thirsty when the level of sodium in our blood,
• 1:04:15
  Speaker 1: which is normally 140 milliequivalents per liter, rises to about
• 1:04:18
  Speaker 1: 141 milliequivalents per liter. So as the water is gone,
• 1:04:22
  Speaker 1: the sodium gets more concentrated. 141. At that point, your
• 1:04:27
  Speaker 1: brain is kicking in and you will find water. The
• 1:04:30
  Speaker 1: only time that doesn't happen is if someone's incapacitated. And
• 1:04:34
  Speaker 1: we'll see people with high sodiums because no one's giving
• 1:04:36
  Speaker 1: them access to water. Or if they have rabies and
• 1:04:40
  Speaker 1: have hydrophobia. Your urine puts out water. It's mostly water.
• 1:04:46
  Speaker 1: And it can dramatically vary the amount of water that
• 1:04:49
  Speaker 1: it puts out. So you can put out about 20
• 1:04:52
  Speaker 1: liters a day of water in your urine if your
• 1:04:55
  Speaker 1: kidneys are healthy. So if you're drinking 10 liters of water,
• 1:04:58
  Speaker 1: you know what? You're just going to pee that right
• 1:05:02
  Speaker 1: back out. And it doesn't do anything special. It doesn't
• 1:05:05
  Speaker 1: help your kidneys. It doesn't kind of clean them out.
• 1:05:07
  Speaker 1: One exception is if you're prone to kidney stones and
• 1:05:09
  Speaker 1: having more dilute urine might reduce the risk of recurring
• 1:05:12
  Speaker 1: kidney stones. I have to say that. But like beyond
• 1:05:15
  Speaker 1: drinking when you're thirsty, there's not great evidence that drinking
• 1:05:19
  Speaker 1: water that frequently improves your health.
• 1:05:22
  Speaker 4: Sorry.
• 1:05:22
  Speaker 2: That's okay.
• 1:05:24
  Speaker 1: Those of you not watching this on YouTube or a
• 1:05:27
  Speaker 1: video platform, I wish you could see the faces that everyone, God,
• 1:05:32
  Speaker 1: everyone hates nephrologists. I, you're, you're boring.
• 1:05:36
  Speaker 2: And I feel that people.
• 1:05:38
  Speaker 3: Are water maxing and you're trying to, you know, like,
• 1:05:41
  Speaker 3: I mean, first of all, do you have an Owla?
• 1:05:45
  Speaker 3: Cause my kids both have those and that's a great
• 1:05:47
  Speaker 3: water bottle.
• 1:05:48
  Speaker 1: Oh, I call it Owala. I do. My kids do
• 1:05:50
  Speaker 1: have some.
• 1:05:51
  Speaker 6: Yeah.
• 1:05:52
  Speaker 1: My kids do. I, I, I, I even like give
• 1:05:55
  Speaker 1: my kids water bottles to go to school every day.
• 1:05:56
  Speaker 1: They all have their water bottles. They refill their water bottles.
• 1:05:59
  Speaker 1: I just like, like from a health standpoint, I'm like,
• 1:06:02
  Speaker 1: as long as they're given access to water, they'll drink
• 1:06:05
  Speaker 1: when they're thirsty. And that is all you need physiologically.
• 1:06:08
  Speaker 3: I do find we've gotten to a point where like
• 1:06:10
  Speaker 3: occasionally if for some reason one of my children forgets
• 1:06:13
  Speaker 3: their water bottle, like they sort of come home with
• 1:06:16
  Speaker 3: this view of like, I almost died at school today.
• 1:06:19
  Speaker 2: I didn't have my water bottle.
• 1:06:21
  Speaker 3: All I could do was drink a small amount of
• 1:06:23
  Speaker 3: water from the, let.
• 1:06:25
  Speaker 2: Me call it a bubbler, a water fountain.
• 1:06:27
  Speaker 3: I had to buy water in a box because otherwise
• 1:06:31
  Speaker 3: I would have died.
• 1:06:32
  Speaker 2: But I guess what you're saying is they wouldn't have
• 1:06:34
  Speaker 2: died that quickly.
• 1:06:35
  Speaker 5: Yeah.
• 1:06:36
  Speaker 1: Correct. I will say, yes, the data is like, you know,
• 1:06:39
  Speaker 1: on like skin turgor and stuff, you know, and there's
• 1:06:42
  Speaker 1: there's look, if it makes you feel good, that's right.
• 1:06:46
  Speaker 1: That's totally fine. But I do think people maybe go
• 1:06:49
  Speaker 1: a little bit overboard with it.
• 1:06:52
  Speaker 2: You can drink too much water.
• 1:06:53
  Speaker 1: Also, you can. It's it's hard.
• 1:06:56
  Speaker 2: Mostly happens when you're running.
• 1:06:58
  Speaker 1: Yeah, yeah, yeah. Water without electrolytes can cause hyponatremia where
• 1:07:03
  Speaker 1: your sodium is too low. So like you dilute your
• 1:07:05
  Speaker 1: sodium and you really need the sodium in your blood
• 1:07:07
  Speaker 1: to keep your brain and heart working. And the treatment
• 1:07:11
  Speaker 1: of severe hyponatremia is very fun for nephrologists, but not
• 1:07:16
  Speaker 1: very fun for the patients that we treat because that's
• 1:07:18
  Speaker 1: one of our diagnoses. All right.
• 1:07:23
  Speaker 2: With that, that's it for us today.
• 1:07:27
  Speaker 3: Stick with us next week when we will ask, what's
• 1:07:29
  Speaker 3: the deal with seed oils? Wellness Actually is produced in
• 1:07:38
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• 1:07:40
  Speaker 2: Our senior producer is Tamar Avishai.
• 1:07:42
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• 1:07:46
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• 1:07:49
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• 1:07:51
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• 1:07:53
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• 1:08:03
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• 1:08:06
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• 1:08:09
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• 1:08:12
  Speaker 2: We'll let the influencers have the last word.
• 1:08:15
  Speaker 5: Hey bestie, here's a little squatty potty hack to help
• 1:08:17
  Speaker 5: you poop easier. So instead of keeping your knees wide,
• 1:08:21
  Speaker 5: you're going to actually let your knees fall in, and
• 1:08:23
  Speaker 5: that's going to create a little bit of hip internal rotation.
• 1:08:26
  Speaker 5: We're just going to open up the back side of
• 1:08:29
  Speaker 5: the pelvis to give space for stool to exit our body.
• 1:08:33
  Speaker 5: We're going to breathe it out, we're not going to strain,
• 1:08:35
  Speaker 5: and we're going to have a nice satisfying poop.