Episode 44: Gut Check: Microbiome, IBS, Reflux, and More with Dr. Sunana Sohi

In this episode, gastroenterologist Dr. Sunana Sohi takes us on a deep dive into the gut microbiome—what it is, how it forms, and why it matters for your health. We explore the gut–brain axis, dysbiosis vs. eubiosis, and the role of prebiotics, probiotics, and postbiotics. Dr. Sohi also shares practical strategies for common digestive issues like IBS, constipation, and acid reflux, plus her expert tips for preparing for a colonoscopy.  Dr. Sohi reminds us that even small shifts toward eating more plants can make a big difference. 

 Small choices for your gut can mean big changes for your health!

Find Dr. Sunana Sohi at Gastroenterology Health Partners.

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specific individual’s medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment. This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

Episode 44: Gut Check: Microbiome, IBS, Reflux, and More with Dr. Sunana Sohi

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.

This podcast does not create a physician patient relationship and is not a substitute for professional medical advice. Diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Welcome to the starting day. We're your host, Dr. Kitty Dotson and Dr. Sarah Sheets. Two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.

We'll help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all.

Welcome back to the starting gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz. Two weeks ago we had a great conversation with Emily McGlone, a dietician here in Lexington, who introduced us to the gut microbiome and gave us some practical tips on how to get more fiber into our diet. But today, we're really gonna take the next step in that discussion and dive deeper into the science, behind the gut microbiome and how this interacts with symptoms we may have in our gut and our gut health in general.

 So we're excited today to have an expert in the field. 

Yes, we'd love for you all to welcome Dr. Sohi. She is board certified in internal medicine and gastroenterology and practices in Louisville. At Louisville Gastroenterology Associates, and we are so excited to [00:02:00] have her here today because she loves talking about the gut as much as we do.

And so can you give our listeners just a little bit of information about you and how you ended up in this profession? 

Absolutely. So first of all, thank you for having me. I grew up here in Louisville, so it is really nice to be back here and practicing. I did my undergrad med school residency and fellowship all away.

So I came back with maybe a ffr, maybe a fresh perspective, I don't know. But I came back with a different perspective than maybe people who have trained locally. And I'm just really glad to be back home. I've been practicing here in Louisville with our GI practice now since 2010. So really, I've been back here a while.

It's back to being home and I've got two kids here as well with my husband. But, yeah, I forgot the question. What was that? 

What made you interested in gastroenterology? 

 So it's interesting. When I first went into medicine, I actually thought that maybe I wanted to do something like psychiatry.

I really liked talking to people and [00:03:00] hearing about their issues. I really wasn't sure what I wanted to do. And when I rotated through all the specialties in third year med school, as you do, you end up gravitating to the ones that are more exciting to you. I loved the cerebral nature of internal medicine.

The teamwork, all the talking, all the differential diagnoses, all the thinking that became involved. But I also really loved the procedural nature of surgery. Being able to use my hands, being able to fix something. So my brother is an ENT here in town, and I remember when I was trying to decide what I wanted to do, he said, Sunana, you should think about gi.

And I'm like, that is gross. No, I don't wanna do that. And yet, here I am. I ended up rotating through gi as a fourth year med student. And I loved it. The people are amazing. We're funny as you would have to be if you swim through poop all day. Yeah. You have to have a sense of humor, right?

You have to. And it's really great to take care of a system that's so deeply connected to the rest of the [00:04:00] body that really affects people's quality of life even if it's something functional rather than structural. And also there's a great need for women in gi. Sometimes some of the things that we talk about are really personal very intimate things.

When people start talking about. Incontinence or bowel problems. And I'll have a lot of people, women, also men tell me well, I've never told anyone this before, but, and then they start talking to me about things. So it's really nice to be that for people as well and specific to the GI tract, which I think people find fascinating, but also icky.

So it's, I like being able to hear people in that way. 

 Sarah and I were talking earlier before we started recording about how much GI has changed just in the last 10 or 15 years, and especially around the hottest topic, the gut microbiome.

And so we'd love for you to just tell us a little bit more about what is the gut microbiome or biota and why has it suddenly [00:05:00] become something that we're talking about? 

so the gut microbiome is a huge topic in GI health right now. It's healthy gut, gut health. There are all the hashtags and the big popular terms that people are looking for.

When we talk about gut health, we're specifically, I think talking more about the health of our gut microbiome, which are the trillions of bacterial, viral, and fungal organisms that live in our GI tract. And they live in this beautifully symbiotic relationship with us. So we actually have more of these cells in our body than we do our own human cells.

we have a really beautiful relationship with them and we've never really known, and we probably still don't know all of what they do for us, but we're just starting to scratch the surface. And when we talk about the gut microbiome, I think it's important to think about two terms, which are dysbiosis and eubiosis.

And I don't know if you guys have covered that before when you've talked about the microbiome, but dysbiosis is basically a reduction in [00:06:00] microbial diversity and a loss of the bacteria that we know to be beneficial. And then a rise of more pathogenic bacteria or bacteria that cause problems. So dysbiosis is associated with disease.

So dysbiosis disease, we want eubiosis, which is more of an optimal balance of gut bacteria. And so I know we're gonna get into this, but it's important just not just for the health of the GI tract, but we're finding that the GI tract is intimately linked to the rest of the body that a gut health or health of the gut microbiome is really important for the health of the whole body.

Yes. And as you bring that up I think that's something I know even in my training I would have or see people talk about this. And even hearing the words gut brain axis, at first I was just very skeptical from how I was trained. And today, now I see the major impact that it probably is having on our health and how important this is.

So let's just go on and go there. Can you tell our listeners what are our gut bacteria [00:07:00] doing for the rest of our body? 

we have long known that our gut bacteria are useful for fermenting fiber into short chain fatty acids. These are. What feed our colon cells and keep our colon healthy.

The fatty acids are also used by the body as a nutrient source, but they actually play an important role in muscle function as well, and possibly in the prevention of chronic diseases, certain cancers and other bowel disorders. The studies that I know show that, short chain fatty acids can be useful in the treatment of ulcerative colitis.

 Crohn's disease and antibiotic associated diarrhea. I think from med school we all remember learning that our bacteria synthesize vitamin K and vitamin B and metabolized bile acids as well. So there's a lot they do for our GI tract. But you mentioned the brain gut axis. Or I'll say more specifically, the brain gut microbiome access, which , we talked about this before we started recording, and there's a lot of terms that at first people hear in medicine and they think, oh, this is like pseudoscience or [00:08:00] fru.

But then as more data comes out, we understand that it's rooted in some truth. So there is a bi-directional link between the brain, the gut, and the microbiome. And studies are looking now at the relationship of the gut microbiome to our brain. We know that our microbiome produces neurotransmitters like serotonin, dopamine, and gaba.

And then these play a role in our nervous system. And I think a lot of people know about serotonin and dopamine already. So the neurotransmitters in the gut that control gut function and motility are the same as those in the brain. And there is a blood brain barrier that prevents crossing of certain materials from the blood into the brain. But when it comes to the gut, the neurotransmitters and hormones freely communicate. So the GI tract has been dubbed the body's second brain. The myenteric plexus is the GI tract nervous system, and so microbes can stimulate the vagus nerve.

I know people have heard about the vagus nerve as well through these neuro po [00:09:00] cells in the gut lining, and they can activate these cells that send hormones to the rest of the body and influence immune cells and I inflammation. So the healthy microbiome is important for the nervous system because dysbiosis, as we talked about earlier, an imbalance in the gut.

Microflora can be associated with inflammation in the brain and illnesses like depression, anxiety, autism, and Alzheimer's. So there's still a lot of research, but that sort of gives. A general overview of the interaction between the brain and the gut. But, the gut's effects on the bodies don't just stop there.

There's there's the immune system. So a huge portion of your immune system is in your GI tract. It's about 70% of our immune system is in our GI tract. And as you can imagine, if your GI tract is filled with all sorts of microorganisms, our immune system has co-evolved with our gut microbiome. So it, it's evolved not only to create defenses against pathogens, but also to develop a tolerance for these beneficial bacteria.

So there's like this [00:10:00] nice symbiotic relationship there, and any inflammation of the GI tract is gonna place stress on that microbiome. And then chemicals like cytokines that can be released, neurotransmitters can be released, and so that can throw off the rest of the body as well. dysbiosis can end up disrupting that epithelial barrier.

The, and we'll talk about leaky gut, I think in a little bit, but it increases our susceptibility to infections as well. 

 And so how does our gut microbiome even start how do we know if it's going to be in a good variety or how do we know if we've got dysbiosis? What would be things that might happen that could lead to that?

Yeah most of us, our gut bacteria, our gut microbiome is going to be most like our mothers. About two thirds of our microbiome is unique to each individual, so that's basically our microbiome fingerprint. And our microbiome most closely resembles that of our mothers because it develops through these early life exposures [00:11:00] being colonized at vaginal birth or interacting with mothers microbes during breastfeeding, for example.

But then diet environment and things like antibiotic use play a big role as well. during the first few years of life, the microbial communities in the body are dynamic and so they're changing significantly. The diversity is being established and we get a relatively stable adult-like stage in our microbiome, probably by the age of three or so.

And I say stable because it is relatively stable from individual to individual, but there is a lot that people can do to influence change, guide, help, and support their microbiome. So when people hear that, oh, my microbiome is fixed for me, it's too late for me to change anything, it's definitely not too late.

There's still a lot that we can do 

and I think that's an important message for people to hear.

What are the things that are gonna get people the biggest bang for their buck when it comes to trying to improve that gut health? 

healthier people, and by [00:12:00] healthier, I'll say people who have less chronic medical conditions, healthier people have a more diverse microbiome compared to people that are less healthy.

 there are many things that can affect the health of your gut microbiome. We talked about antibiotic use. As we age, we lose some of our core bacterial species. Interestingly, diets that are centered around meat and animal products have more of a certain pathogenic bacteria that can promote inflammation in the gut.

So really there's a lot of things that we can do to feed and nourish our gut bacteria. But feed is the key word because we have to feed ourselves and as we feed ourselves, we're also feeding those trillions of cells in our intestines as well. So what we've seen is that diets rich in plant-based materials are associated with a greater diversity in the microbiome overall.

And remember, a healthy microbiome is a diverse one. And the good thing is that changes in the diet can alter the composition of the microbiome pretty quickly. So there's a lot that people can do in the way that they eat to [00:13:00] help their microbiome, but you do have to stick with those changes if you wanna keep that diversity.

There was a study that was done looking at rugby players and they had them alter their diets and they found that in the washout period after people stopped eating a certain way, their microbiomes returned to their baseline. And that just reminds us that whatever changes we want to make to feed our microbiome, just like the changes we wanna make for our overall health, there's no diet.

It's more of a lifestyle. How are we gonna live to nourish ourselves and our microbiome? So for the microbiome eating a plant-based diet with a lot of variety can be beneficial. And the way I like to think about it is, our gut bacteria ferment fiber. So what they want is fiber. That's what they eat, that's what they like.

So when we talk about creating a healthy environment, we wanna feed these bacteria the things that they like. And we have lots of different bacteria in our intestine, and we want that diversity because a [00:14:00] diverse microbiome is a healthy one. So I've said it again, but it bears repeating that when we talk about dysbiosis or an unhealthy microbiome, we're talking about a less diverse microbiome.

So fiber is key. The USDA recommends 25 to 30 grams of fiber per day. The bad news is that's probably not nearly enough fiber. That for all of us, but it's a good starting off point. The good news is that if you eat a Whole Foods plant-based or heavily plant forward diet, you're gonna achieve that easily without even trying, because there's just so much fiber and fruits and vegetables, beans, legumes, nuts, grains, and so you don't even have to count.

The thing that makes it a little bit more complicated is you know, you guys have your favorite foods, right? And your favorite food may not be the same as my favorite food. And so we don't all eat the same thing. And the same thing goes for our gut bacteria. So we know that our guts want fiber and they want lots of it, but each little bacteria has its own preference.

So it's got its own favorite food. So some may like a certain [00:15:00] plant fiber more than another. So in order to maintain a diversity of bacteria in the gut or eubiosis, we can't just eat 25 or 30 grams of kale per day. Or quinoa or any one plant fiber and really, who would want to, yeah, that's a lot of kale.

We need a diversity of plant fibers because each of those little bacteria wants something slightly different. So really the key to healthy microbiome is not just the amount of fiber, but the fiber diversity. And that's why I love the idea of rainbow eating because when you eat the rainbow and you're picking foods that are different colors and different types, you're getting that variety of phytonutrients, which is great for you.

But then you're also getting the fiber variety as well. So one of the tips that I, like to give people in thinking about how to increase their plant diversity is to make it a game, which I ended up doing with my family during the pandemic with my children.

So a recent study looked at people who ate 10 or few different types, 10 or fewer different types of plant fiber per week with people who [00:16:00] ate 30 or more different types of plant fiber per week. And they found that those with 30 or more plant fibers per week had a more diverse and therefore more healthy microbiome.

So if you're like goal oriented person, then you aim for 30 different plant fibers per week and. Obviously sounds daunting, but if you take into account things like herbs and spices along with your grains and legumes and veggies and fruit, you can get to 30 pretty quickly. And at one point in my family, we had this thing up on the fridge and we were all competing to see who could get to 31st.

This is how nerdy my family is. But it worked pretty well. My kids roll their eyes, but they definitely do go for plant diversity. And even something as simple as getting a different type of apple or a red pepper, a green pepper. Kale, of one type, like dinosaur kale, a flat leaf parsley, a curly leaf parsley.

They're all slightly different. And just not shopping the same stuff that you always shop can be really helpful to give your microbiome [00:17:00] slightly different types of plant fiber and giving it that diversity that it needs to be healthy. This is a game that Dr. Dotson 

loves 

as well. I love this game.

Yeah, I love the 30 plants a week. Yay. Actually, I'm bad about getting the same type of apple, so I'm really glad you brought that up because that would help me 

even more. I love cosmic crisp apples. Your honey crisp. Honey crisp. Have you had the cosmic crisp? Gosh, I don't know. Had that cosmic crisp?

I know if I've had. They're like better than honey Crisp. I hate to say it 'cause Honey Crisp were my favorite and now it's the Cosmic Crisp. So there you go. There's your one additional. Try a cosmic crisp this week and see what you think and maybe I'll step back to a honey crisp. Yeah.

Yeah, 

I'll try a cosmic crisp. And even just the parsley, 'cause I tend to like flat parsley better, so I tend to get like Italian flat leaf pars, parsley, and that's what I grow in my pot this summer. But yeah. But yeah, even mixing it up, so that's a great idea, Sarah and I like to promote seeds as a way to help get those [00:18:00] 30 plants in.

But but you've given me a good thought today too, so that's great. 

Oh, yay. I am so glad. , 

So someone may be listening to this and think, I feel fine. My stomach feels fine. I'm not worried about gut dysbiosis. Are there symptoms or are there things that would make someone stop and think about it and be more motivated to make these changes?

Yeah, I think it depends on your outlook on life too. I like to think of our bodies as the only house that we'll live in for our entire lives. And so what do you do to take care of your house? And just there might be things in your house or let's say your car that seem to be working fine, but occasionally need to be replenished or checked on or tuned up.

It's the same thing with your body. Like it's not, maybe it doesn't feel like it's broken now, but there's lots of things that are potentially going on in people's bodies that they don't know about. I don't wanna use the biggest and scariest thing, but people can have cancer. And feel [00:19:00] fine and not know, right?

So just because we don't necessarily have a really obvious signal from our body telling us that there's something maybe unhealthy or less than ideal doesn't mean that we shouldn't try to do what we can to nourish our bodies the best. But that motivation obviously has to come from within, right?

Because if someone is eating a certain way and we're asking them to make these huge, drastic changes, they have to figure out their why and their why really has to be at the top of their head. Because if you are externally motivated by somebody else pushing you to do something, it's just not gonna work.

You have to know why you want this thing, why you want to eat, live, exercise, sleep, be outside, whatever you wanna do to take care of yourself. And then you have to keep that in the front of your mind when you don't wanna do it, because we all don't wanna do it sometimes. Whatever it may be. But what makes us keep going is that determination.

[00:20:00] And so with someone that might have, let's say leaky gut or dysbiosis, they might feel totally fine or does that typically make someone have any particular symptom like constipation or belly pain or something like that? 

It can, but it also, people can also feel totally fine. And it's funny because I was at work the other day and sometimes I say things and sometimes I don't.

But we. Got lunch as our whole endoscopy center. And it happened to be a very plant heavy lunch. I think it was salads from someplace. And one of my staff said something like, yeah, you know, I don't mind how this stuff tastes, but it really does a number on my gut later, and this person's living a great life and has a wonderful life, but when this person eats greens or salads or whatever, they end up having some bowel issues later and.

I didn't wanna say that is because, but really in all likelihood, that is [00:21:00] because their gut bacteria is much more in tune to eating meat and less plants. And so then when they start introducing things that their bacteria is not used to, it causes them distress. And so to them it can end up feeling like these foods are actually the problem foods for me.

But what is likely going on is that their gut bacterial balance is in dysbiosis. They probably have a very high number of, some of these, we'll call them like bad microorganisms that tend to thrive in a more meat heavy environment than the bacteria that would tend to thrive in a more plant heavy environment.

And so changing that. Can be difficult because you don't wanna introduce a whole bunch of fiber all at once to your diet if that's not something that you're used to, because it will make you feel bad because your gut bacteria is not used to that because your balance is not in line with the type of balance that would benefit from all this [00:22:00] variety of plants.

So that transition has to be made more smoothly. But I bring that up as an example of just you can think you feel fine and still be in dysbiosis based on what you're eating or basically what I'm saying is I think it's really unlikely that if you're not eating a good amount of fiber and a good variety of plants that you are in eubiosis, even if you feel fine.

You might be, I have no way of knowing myself, but the likelihood is that everybody could benefit from increasing more plants and more plant fiber in their diet. 

It's hard to tell how it's going. And it makes me ask the question, so do we not have good accurate tests for people to actually test their stool and see what their microbiome looks like?

'cause I know they're sold, but are there current tests that can actually give us that data? 

 Honestly, not ones that I recommend. There may be tests out there and it's possible some of those test [00:23:00] manufacturers will listen to this and be angry at me. But there aren't tests that are really well supported at this time.

I think that will change. We have some idea of what bacteria are good and some idea of what bacteria are bad, but like we said, there are so many different kinds and we don't necessarily. Have a great test to, and a great guideline to follow in terms of you want to have this amount of this bacteria and this amount of this fungus.

 but we do know that eating a variety of plant fibers does increase your diversity. And so I know because I'm goal oriented as well, so rather than testing your microbiome and then eating a certain way and then testing it again, I think just thinking about the big picture in the long haul and if you have to have some sort of goal or something to like, look for that number of 30 and aim for that diversity and just know that is good for you.

And I mean, we all kind of know that's good for us. It's, some of this to me [00:24:00] seems like it's pretty. Intuitive for people because we've all been told, eat your vegetables since you were little. So we know that eating plants is good for us. I know some people may want a test to prove it, but I wouldn't recommend spending your money on that.

I would probably rather recommend you spend your money on the food itself, like the healthy, we 

do have that research to show it makes an impact by eating the food. 

 Yes. Can you tell us a little bit more about the impact of meat and does it matter what type of meat, how often you eat it? Yeah. 

Yeah. When I, and I will preface this by saying that I am a hundred percent plant-based.

So to me there are lots of other reasons to avoid eating animal products outside of my microbiome, but within the realm of the microbiome itself, we do know that red meat. Is definitely bad and red meat has been associated with all sorts of cancers. So if you and I say that [00:25:00] though, I am a hundred percent plant-based, I know that there are many ways that people can live in a healthy way while also incorporating animal products into their diet.

So I don't think it has to be an all or none if we're looking at the perspective of just the health of the microbiome. But I would say that you want, basically, when you're eating to think about the majority of your plate to be the fruits and the grains and the greens. If you think about your plate as like a clock, you really do want from like noon to nine to be all the fruits and grains and greens and vegetables.

And really only a quarter of it should be that kind of animal product or whatever it may be, meat or eggs or some sort of dairy. The more plants you get, the better. The less meat you get, the healthier. But that doesn't mean it has to be all or none. I think that's a good clarification on that, so thank you.

And for someone that let's say is a picky eater and they've got two [00:26:00] or three fruits and vegetables that they like and they eat those all the time and they're resistant to expanding their palate, is that person someone that should take one of these green supplements or should they take a probiotic? Or how can someone expand that?

 There's not a lot of data on some of this stuff. I would say that probably a green supplement is better than nothing, but it's never gonna be the same as actually taking the entire plant in because with the green supplement, it's heavily processed, right? And you probably don't get the same type and amount of phytonutrients, and you definitely don't get that fiber.

Some people find that they like it, and so if it works for them, I say, more power to you. But I will constantly be pushing this whole time on just spending your money on food, because I think food is medicine, food is the root nutrient. It's like the best medicine that there is. But it can be hard to readjust your palate.

And some people don't want to, right? So if they don't want to, they don't [00:27:00] want to, it's fine. And if they feel like let me just take this, powdered greens. And that works for them, then great. I think that's a step in the right direction. Raising my kids 'cause we are all pretty plant heavy and plant-based has been interesting because there have been times you can change your palate is basically what I'm gonna say.

So with my kids, I always make them taste and they've done studies that show that you have to taste something or eat something at least five times before you really know whether you're gonna like it or not. So when they were little, I'd be like, it's fine. I'd hold out my hand, I'd be like, you can spit this in my hand if you want to, but you have to taste it.

And the example that I'll give you is my son in red peppers because he hated red peppers, hated them when he was like three or four. And every time I'd be like, you can spit it in my hand, you can spit it in my hand. And now red peppers and hummus, just eating it right up, and I didn't force it on him.

I just said, you just have to taste it. So I think. It depends on how willing people are to change and willing people are to try. And [00:28:00] if they are, then I think it can be done. And if they're not, then these supplements are out there and it's definitely better than nothing. I know you asked about probiotics and I think we wanted to talk a little bit about prebiotics and probiotics and how we can get these and postbiotics so to give people an idea of what these things are.

prebiotics are these non-digestible fibers that are good for your gut bacteria. An example of that would be inulin. They're usually found in food sources, like again, fruits and vegetables, fruits, grains, beans, vegetables. So there are supplements out there that are prebiotic supplements. But again, I feel like, I know I'm a broken record, but I'm gonna say it again, it makes most sense to just get your prebiotic from the actual food source, because then you get the phytonutrients too.

Probiotics are live microorganisms that are purported to improve the microbiome. The thing about probiotics is that they fall in the category of a supplement and not food. So they're not really well regulated by the [00:29:00] FDA. And I know at the beginning there may not have been that many out there, but I think we've all seen that the probiotic industry is quite robust and super overwhelming.

So you go to the the drug store and you look and there's like a huge wall of different types of probiotics and it can be very overwhelming to figure out what to take. Interestingly, there's really very little good data on specific probiotics for general health or for things like IBS or irritable bowel, for example.

There is some data on probiotics for certain situations like an infection in the GI tract called C diff or certain inflammatory bowel diseases. But on the whole, there's not a lot of great data on probiotics. So that said, if people come in and they're telling me they're on a probiotic and it works for them, I say the don't rock the boat.

If that works for you, keep using it. It sounds great, but just like we're not sure exactly what bacterial balance we all want to aim for, and we don't have these great tests that are gonna show us eat this way. And then let's look for the number of these [00:30:00] colonies and these colonies we don't really know right now, which are the best bacteria and in what proportion.

So rather than spending your money on probiotics if you're not already on one, it makes more sense to me for someone to take that $30 a month or more and put it towards a variety of foods. And then postbiotics are the compounds that are produced by the gut bacteria when they ferment the prebiotic fibers.

So we talked a little bit earlier about short chain fatty acids and vitamins B and K and certain amino acids. So you could certainly take short chain fatty acids and in certain GI tract conditions, we actually will prescribe them for colon cell health. But also you can increase the amount of useful postbiotics in your system by increasing your intake of foods that are gonna nourish your gut bacteria and fermented foods, which I didn't get to talk about yet, but things like kefir and Tempeh and kimchi, the fermented foods also offer these health benefits.

[00:31:00] And then they also reduce inflammation and support the immune system so they can improve digestive health as well. 

I know we've talked a lot about kimchi and sauerkraut and things, but you mentioned Tempe and that was when I was leery of trying initially, but I tried it about a year ago and it's so easy to.

Cook and then put on a salad or something. It's a really easy source of both protein and fermented food, and it's cheaper than meat. And so it's something that, if you are wanting to experiment with some of these plant-based things, I think it's an easy one to do. 

Yeah, I think you're right.

And I think it's really great that you brought up the point that it's cheaper than meat, because I think one of the things, and we have to think about what are the barriers to people eating for themselves. And we do know when we talk about factors that are involved in eubiosis and dysbiosis, that certain areas with lower socioeconomic success tend to have less microbiome diversity.

And so I think it [00:32:00] can be very difficult. , And it also can't be, but the thought that eating a plant heavy diet is more expensive than eating a diet that's rich in meat, I think needs to be argued against. And we need to help people see it takes more effort.

That's the issue. And people also don't always have the time to make that effort. So there are a lot of barriers. But it can be done. It can be done. It does require some guidance. It requires some thought and some planning. But some of these things, once the thought and planning is done once they can go on autopilot.

But it would be naive to say that there aren't barriers in society to helping people eat better. And that's something that I think we all need to work on. 

And another thing that comes up when we talk about this is how does alcohol impact our gut microbiome? 

 Yeah, so it's interesting I actually first heard about the gut microbiome during my fellowship at Rush University back in, I was there from 2007 to [00:33:00] 2010.

And what was happening at that time is a senior fellow was doing a study looking at. The effects of chronic alcohol use on the microbiome. So this is, more than 15 years ago is when I first started hearing about the microbiome and that just tells you how long the research has been going on and how long it will continue to go on.

'cause there's still so much that we need to know. But what we do know is that chronic alcohol use is associated with dysbiosis and it can increase intestinal permeability as well. So when we talk a little bit about what is leaky gut it can definitely increase mucosal permeability. So this, the dysbiosis can lead to all sorts of issues as we've discussed.

But basically the long and short is that regular alcohol use can lead to an increase in your bad bacteria. 

And when you mentioned regular alcohol use, is that something as small as just one drink a day? Or does it need to be something where people are drinking three to five drinks a day 

Unfortunately it's basically anything consistent. And I think for the longest time we used to [00:34:00] tell people like a glass of red wine a day is okay. And unfortunately that's really not the case. We're now finding out that really no amount of alcohol is considered healthy or safe. , It's very commonly used in our society, so it doesn't mean that people aren't gonna do it.

I think they just need to acknowledge it for what it is. a new plant-based cinnamon roll place opened in our city a couple days ago, and I did take myself to have a big old cinnamon roll and I am aware that is not healthy, but it was delicious. But part of eating is pleasure, so people have to figure out that balance for themselves.

But I just don't want people to convince themselves that it. It's healthy, it's not, but that doesn't mean that you can't do it. You just have to do things in moderation and understand that it might be affecting your microbiome. 

Yeah, I think that's a good way to think about it. 

One of the last things that you had touched on is antibiotic use and how that impacts your microbiome. Can you just give a little bit of [00:35:00] information on that and how people could help protect themselves in that sense? ' 

Absolutely. So antibiotic use, as you can imagine, because it's an antibiotic, it can definitely affect the balance of your gut bacteria. So antibiotic use, especially chronic or repeated antibiotic use can be associated with dysbiosis. Antibiotic use can be associated with bad infections in the GI tract.

The one that we all know is called c diff because anytime you put antibiotics in your body, they're affecting your microbiome because anytime you put anything in your body, it's affecting your microbiome. And what can happen is this bad or pathogenic bacteria can grow up and wreak havoc. And that's what happens with c diff.

It basically causes a lot of diarrhea, a lot of discomfort. We. Definitely need antibiotics at certain times in our lives. But I think it's important for people to realize that antibiotics are also really overprescribed in our country and that there are many times where people maybe get an antibiotic that they didn't really need, and that we [00:36:00] have to think about it, that it's not without risk.

So if you have some like upper respiratory symptoms and you're not sure what it is being evaluated rather than calling in and just asking for an antibiotic is probably a. Better thought. So if we can minimize our unnecessary antibiotic use, maybe just by minimizing how much we request them that will do a lot for our microbiomes as well.

Always. That 

was something I would try to teach patients is I think one of the best ways is to always ask is do I really need this antibiotic or not? 'cause I would love to not have to take it because I think in healthcare for a lot of times is sometimes providers are prescribing just because they're getting this demand constantly to get the antibiotics.

So to help your gut out you can always approach an appointment, okay, I will take this antibiotic if I really have to have it, but if I don't need it yet, please let me know 'cause I don't want it. And that's a way you can advocate for yourself and communicate with your healthcare provider. [00:37:00] Yeah. 

 . And there is some data looking at maybe probiotic use during antibiotic use as being helpful to prevent c diff infection, for example. So there is one probiotic out there Saccharomyces boulardii that has been shown to be helpful at prevention of c diff infections or recurrent c diff infections with antibiotic use. So there is a role for probiotic sometimes. 

And if someone was taking an antibiotic and wanted to take that probiotic, would they start it when they started the antibiotic and then how long would they continue it after the antibiotics? 

Yeah, so they would, I would start it at the same time and then continue it for like maybe a week or two after.

Yeah. I know that's one time that I'm usually take a probiotic and not just eat my probiotics is if I do need an antibiotic. Because it just makes sense to me that's when you would need it the most. 

Me too. Yeah. 

So you mentioned leaky gut a few times. Can you tell us a little bit more? I feel like that's in the media a lot too.

What exactly does that mean and what happens to us if we have it? 

 [00:38:00] . So leaky gut refers to increased intestinal permeability. And it is a huge buzzword and I think it's not commonly recognized right now.

There's not a common test for it. We're not entirely sure yet what it means because I know it's very common out there on the internet, but it's hard to say what it actually means. But dysbiosis, we know can damage the gut lining and then leaky gut can further disrupt the microbiome. Or like intestinal, increased intestinal permeability, I'll say, can further disrupt the microbiome.

So it becomes this feedback loop that's harmful where gut health deteriorates. , We have these junctions between our intestinal cells where they're very closely opposed and nothing can get between them. So that means everything has to go through our intestinal cells. That's how we end up.

Absorbing our nutrients and weeding out the bad stuff. But when these linings of the intestines become damaged, harmful substances and toxins can slip through the cracks basically, and go in between these [00:39:00] cells. And I, as I said, it's not in and of itself, formally recognize medical diagnosis, but increased intestinal permeability is associated with things like autoimmune diseases and allergies.

So we know that there is an increased intestinal permeability in certain situations, but what that actually means, how one would actually test for it what you would do about it is still up in the air. 

The only other thing that I would add in terms of taking care of your gut microbiome and looking at ways to nourish it, obviously we've talked about diet but there's other things that you can do. There have been studies in the New England Journal looking at our body circadian rhythm and gut motility, and they're suggesting, actually, and this is not something that I do, but there's a suggestion that maybe with intermittent fasting or time restricted feeding, , that there is some improvement in motility that can actually help the gut microbiome as well.

We do know that exercise has been shown to affect the microbiome. And I mentioned earlier this [00:40:00] study about these rugby players and they compared the microbiome of a team of rugby players to these matched sedentary controls and showed that there was more bacterial diversity in the athletes. And that's the study that I was talking about earlier where they did a washout period and then the diversity of the exercisers reduced.

When they stopped what they were doing that was helping the microbiome. Stress has been shown to affect the microbiome and can increase levels of colonic inflammation. And stress has been shown to affect intestinal permeability as well. So when people are thinking about what they can do to help their microbiome, aside from eating well things like meditation and other things that help regulate the stress response can suppress this kind of chronic inflammatory state and help with that healthy gut barrier function.

And sleep deprivation is the same way sleep deprivation has been associated with dysbiosis. And actually a healthy gut microbiome has been shown to play a role in sleep quality. Linking back to that brain gut [00:41:00] microbiome access that we talked about before. So all that is bi-directional. And I think the last thing I would say is that time and nature has also been associated with eubiosis.

When we're immersed in the great outdoors, we're like basically bombarded by environmental microbiota. A thimble full of soil contains billions of microbes. And so exposure to these microbes boost the immune system and can add to the microbial diversity. So there's a lot of different things that people can do in addition to eating well to help their microbiome.

And these are things that we also just think about ourselves in terms of boosting our overall wellness, right? Exercising, sleeping well, spending time outdoors, stress reduction, and eating well. It's so simple, yet so difficult. 

It is, and it's true. And these same things we bring up over and over again with so many different conditions.

We've done lots of shows at this point and it's just. They can have such a huge impact. And I think people are starting to realize this, but then it becomes the next question how [00:42:00] do I accomplish it? And that is something that it's not gonna come easy. These are definitely things that our environment has set us up for a very hard road, and we have to realize that it's gonna take some time and energy and commitment in order to improve any of these lifestyle pillars.

Yeah, 

but remember, , you don't have to do everything perfect. So if you need to start by getting outside and getting your hands in some soil for a few minutes, then that would be an easy one to add to your week. I think you mentioned stress and. I had to understand a little bit more about how stress affects the gut because I feel like I saw patients very frequently that would have a lot of different GI symptoms when they were under more stress.

And I think everyone's experienced some time in their life where they've had something suddenly happen that's stressed them out and they've had to run to the bathroom. 

I call 'em the stress poop. 

 So what is that whole connection? 

Yeah. Ev [00:43:00] I feel like a lot of people have that right. And I. I, we do know we talked earlier about the brain gut connection.

So we know that the GI tract produces a lot of neurotransmitters and that there's a lot of nerve endings in the gut as well. But I think we're getting into the. The talk about irritable bowel. So what irritable bowel is it's an altered motility in the GI tract and potentially an altered sensitivity to the GI tract.

The structurally the GI tract would look fine. If you were to go do a endoscopy or colonoscopy on someone, everything would look fine. They wouldn't technically be inflamed, but people feel inflamed, right? Things are hypersensitive, and there are different types of irritable bowel. So people with irritable bowel that are diarrhea predominant things tend to move a little quicker when they're excited or anxious or stressed.

People with constipation, predominant irritable bowel, things tend to move a little bit slower. And then there's versions of IBS where it's mixed or there's versions of IBS, which are more like pain predominant or pain sensitive. [00:44:00] Bloating people put a lot of stress in their gut.

So that can be really difficult. All but all of the things that we've talked about that help regulate the microbiome are gonna help regulate that as well. And stress is one of them. So whatever technique you have to modulate your stress, whether it be prayer or time in nature or meditation I think that's our world is so fast paced and we are so used to being busy all the time.

It's really hard to sit quietly and just be present. But that, that I think is really helpful, not only for our minds, but for our microbiome and for our whole body as well. And then obviously for irritable bowel, if you have any GI symptoms, you should go see a, physician or a healthcare provider because you wanna make sure you're not missing anything worrisome.

But then there are also medications that we can use that can help support people as they go through these things. 

And when it comes to IBS, is that something that people tend to deal with their whole [00:45:00] life or is that something that perhaps when they're working on some of these lifestyle factors, that it can improve and resolve some of their symptoms?

I think a lot can be resolved and taken care of depending on the severity based on lifestyle changes for sure. 

So there's so many different symptoms people can have with their gut and then there are infinite more over the counter remedies that are out there that people can use to try to help.

Are there anything out there that you feel like you see patients using frequently that they should really not just be treating their symptoms with the over the counter, that they should be coming to be evaluated by you? 

 Yeah, so thankfully a lot of these over the counter meds do have a label on them saying that if you need to use this medication for more than X amount of time, you should seek care of a healthcare professional.

And I think that is good that they say that. I think any symptom that is new warrants an evaluation even if it seems like it's something minor like pain or a change in the bowel habits. If it's new, it probably needs to be seen at least [00:46:00] once. So if you have something going on, you wanna get evaluated at least once by someone.

In the healthcare field, a physician or another healthcare professional, just to make sure you're not missing something big. There are certain things that we call alarm features that definitely warrant a more intense investigation, and some of those would be like severe abdominal pain or weight loss blood in the stool.

So those are things that we see that are a bit more worrisome. There are some over the counter medications that are actually okay to use for a more prolonged period of time, but I would counsel that is usually under supervision of your physician. As long as we know about it and we have discussed it, and we're sure that there's nothing worrisome happening, some of these things you can use as needed for your own issues, but ideally you would've discussed it with somebody first.

 A symptom that I constantly see this approach of just reaching for the over counter medications and not thinking [00:47:00] about lifestyle is reflux. In your practice, what are some of those lifestyle changes that you recommend for patients to try to control their reflux better? Instead of always needing to take a chronic medication to manage it, which some people may need it, but not everyone.

Yeah, absolutely. So you're right that. People do reach for those medicines a lot and there is there is a role for them, but there are definitely things that people can do to help their symptoms without medication. Some of these lifestyle changes that we talk about are not eating super close to bedtime, and I feel like that is probably the number one thing that is very difficult for people to do, but could make the biggest change.

as we've said over and over again, our society has not set up for us to be successful in terms of taking care of our bodies. And with as busy as we are, sometimes it is really hard to, you eat early enough in the evening to allow time for the food, to leave your stomach before you lay down to bed.

 I know [00:48:00] many people will eat at 9:00 PM and then go to bed at 11. So when you. Eat and then lie down. You don't have the beneficial effect of gravity to help keep food, digestive content, stomach acid from washing back up into your esophagus. So for sure, giving a window of at least four hours between eating a meal and lying down can make a huge difference.

That and walking around because walking around after a meal stimulates some intestinal motility, so that can help things move down as well. There are certain foods that we know that are more triggering for reflux, like acidic foods, like red sauces and tomatoes. Chocolate. Sometimes we'll loosen the lower esophageal strength.

I hate when I have to break that bad 

news , but for some people it's okay. Potentially sleeping with the head of the bed elevated is another thing that people can do. Just because again, gravity can be our friend. So those are things that people can do to help if they have chronic reflux symptoms.

And [00:49:00] sometimes that is enough, but if it's not, there are a ton of medicines out there. And sometimes people do need an evaluation with an endoscope just for us to look around and make sure that there's no problems happening because of it. 

Do those acid reducing medicines have an effect on the gut microbiome?

 they can, there have been some studies looking at some of these acid reducing medicines and certain GI tract bugs, like c diff again that one that causes, gut infections and diarrhea that we talked about earlier and h pylori.

So for sure by altering that stomach acidity, they can, but they also can serve a benefit. So in some people they do need them. I don't necessarily vilify these acid reducing medications. They're really heavily used. And whenever I see someone on them, we try to talk about ways to get them off of them.

But as long as we talk about the risks and the benefits and we make sure that we've done everything else we can. If someone needs to be on them, like any other medication, if you need it. [00:50:00] But I think there are a lot of things that can be done to keep people off of them. 

Yeah, that was one.

I just, I feel like people start 'em and then there's never a discussion about, do we need to continue with this, forever, and they just end up on 'em for a very long time. So that is definitely one to discuss with your healthcare providers about what is our plan here?, Do I need this lifelong?

Or how long should I take it? How should I get off of it, 

And people don't realize sometimes that when they take these medicines, your body does respond to it. So with some of these acid reducing medicines, when people take them,

the stomach starts to upregulate some of the cells that produce acid to balance what's going on. And so when then you come off of these medicines, all of a sudden you can have what we call a rebound acid hyper secretion. So people try to come off these meds and they feel terrible and feel worse, and they feel like they're gonna be stuck on them.

So sometimes these are ones that it's easier to wean off than to stop abruptly if you've been on them for a prolonged period. 

I think another one that we see so often people struggle with is [00:51:00] constipation What lifestyle guidance do you give to people for that? 

 See previous conversation No, I know they all were tied together.

 diet can play a role. Diet and activity can play a role. There was a study that came out relatively recently that I thought was fascinating, which showed that two kiwi a day are as effective as a dose of MiraLax at inducing a bowel movement. so something, as I say, simple something because not all of this is easy, right? But something as simple as increasing certain foods in your diet can help with constipation and movement as well. Exercise is shown to stimulate gut motility so that can play a role as well.

There's lots of constipation 'cause people are on lots of pain meds and opiates as well. So that can play a role. There's lots of things that can lead to it, but. There's definitely things people can do, and then if they can't, there are medications as well that can help. 

And we had a conversation a few months ago with a pelvic floor physical therapist, and she was telling us [00:52:00] what she could do for constipation, which was actually really new for me.

I, I wasn't aware of how much pelvic floor therapy can help someone with constipation. Have you seen that in your practice? 

Oh, yes. And I think because at the beginning we talked about being a woman in GI and being able to talk about some of these more intimate things with people for sure. Pelvic floor dysfunction, I think is an under-recognized cause of constipation.

So when I talk to people about constipation, we will get into the specifics of. How it feels and does it feel like it's getting to the opening and then you just can't get it out? Because that is very different than if it feels like it's just sitting throughout your abdomen and it won't move.

But pelvic floor dysfunction is really common, but it's not just in women and it's not just in women who have had vaginal births. You can see it in younger people as well and men as well. So it's definitely worth talking about and thinking about if you think about it, this like squatty potty that was made.

We are, our western toilets are not designed for optimal bowel movements because [00:53:00] the angle of the pelvic floor is too short when we sit up like this. , There's a lot that goes on into the movement of the pelvic floor and having a healthy bowel movement. So yeah I love the local pelvic floor physical therapists.

They're amazing with what we can do. 

 We like to ask many of our experts about some of the most common social media myths or misconceptions that are out there. Can you speak on these gut cleanses that are being advertised are they dangerous?

Are they helpful? What should we be thinking about when people talk about a gut cleanse? 

 there's a misconception that our guts should be totally empty at periods in our lives. I've heard people say that they have heard that there's stuff sitting in our colons from three years ago, and it doesn't work that way. As long as someone has a relatively healthy bowel motility, things keep moving through, but things keep coming. So there's never really a time unless you prep for a [00:54:00] colonoscopy where your GI tract should be totally empty. And in fact, we've spent the entire hour talking about the microbiome.

So when you flush out your gut, you're flushing out all your gut bacteria as well. And if you have a generally healthy gut bacteria, it's hard to say how you'll repopulate. So sometimes these flushes and cleanses can actually do more damage than good. 

should we be taking probiotics after a colonoscopy prep?

So typically not, there's not a lot of data because most people end up just recolonizing as they have been. We talked about how everybody gets set up with their bacterial balance when they're three or so, and it just stays very, there's stuff that you can do, but it can stay more or less the same.

So really it's rare that I will have somebody tell me that after their colonoscopy, they had some GI symptoms, and in those cases I might recommend a probiotic, but typically most people don't need it. Okay. 

I just, that immediately was like, oh, wait. Yeah. Since you brought [00:55:00] up colonoscopies, we talked about colonoscopies two episodes ago when we talked to Dr.

Patel about colon cancer, and we're talking about just making sure you were clean. But as someone who actually does colonoscopies, can you just give people some advice about what they wanna make sure they're doing correctly to adequately prepare for a colonoscopy? 

Oh my gosh, yes. So the most important thing besides signing up to get one that someone can do to aid in their successful colonoscopy is to do the bowel prep.

Really, because if there is stuff in the colon and we can't see, we could miss things that are small and then we give someone a clean bill of health and then later on something that was hidden turns out to be something big. So if you wanna do it once in 10 years and you wanna do it right, then you wanna do it as well as possible.

And so what you can do as a patient is basically make sure that you do the cleanse properly. There are so many different bowel preps out there, and they're all [00:56:00] pretty effective. They're all gross. They all make you feel yucky, but they're all manageable. And the discomfort from a bowel prep is far better than the discomfort from colon cancer itself.

I like to remind people of that it's, it doesn't, it's not great, but like you gotta get it done. So all the stuff that we talked about eating well for your gut goes out the window when you're eating for a colonoscopy prep because when you're prepping, the goal is to flush everything out and all those healthy nuts and seeds and grains that are good for your gut bacteria and you want to travel down to your colon and nourish your gut bacteria.

You don't want those in your colon when you're doing a bowel cleanse 'cause they don't cleanse out. They don't flush out well. So really. I think it's hard for people to understand because I'm telling them normally I want you to eat really well, but for this five days or so, leading up to the colonoscopy, you should eat like garbage.

But really you want to eat like a low residue diet. So stuff that's [00:57:00] soft, that breaks apart easily, that doesn't mean you can't have, like I told you, I'm a hundred percent plant-based and I ate that way for my colonoscopy prep. So I had mashed potatoes and tofu and things that are easy to break down because if you have summer salad and you got bits of corn in your colon doesn't wash out super easily.

So really a low residue diet can be helpful. And then just following the prep as well as possible. Hydrating really well in between. The prep is really important too, because oftentimes people will get the prep. That's like a big jug, but then a lot of times people will get a prep that's low volume, and taking in some extra fluids will help flush things through too.

And then the advice that I give people too, because this prep, it's you're feeding your body some poison. It's giving you diarrhea, right? So the body likes to reject it. So if you feel nauseated at all when you're taking your bowel prep, I tell people, you just stop. You wait half an hour and let whatever is going on in your stomach, [00:58:00] move on through.

And then you can try to come back to it a little slower. Because if you continue to try to drink the prep through the discomfort, you're gonna end up vomiting and that feels terrible. And then your prep's ineffective. And you've done all this for nothing. 

 I feel like we've gotten a similar message from you today when we've talked about various GI issues that people may experience. So just can you give us your last thoughts on someone that's looking to make a healthy gut, make a healthy gut microbiome and try to minimize any discomforting symptoms?

What would be our takeaway from you today? 

I think the takeaway is that the best way to feed your microbiome is to eat a diet that's low in processed food and high in plant fiber and diversity and add some fermented foods too. So basically in three words it's eat more plants. 

I love it. You've given us so much great information today.

We really appreciate it and I think that we all feel motivated to go try to eat more plants. Today. 

 Hopefully you all have [00:59:00] enjoyed our GI series so far. We have had amazing guests and we're going to wrap up this idea talking about gut health and swing the other way. And we're gonna actually talk about food allergies next week because we know a lot of people get confused when they're talking about food allergies.

So we have a special guest, Dr. Shauna Ritter. She's a allergist here in Lexington and she's gonna break down that understanding in what makes something a food allergy, what makes something a food intolerance, and make it easier to understand because I know that's something that's also a hot topic on social media.

If you all have any other ideas for shows, please feel free to send us a text or email us at contact at the starting gate podcast.com. We look forward to talking to you next week. See you next time.