PLEASE NOTE: This is a minimally-edited transcript that originates from a program that uses AI.
Anita Rao
This is Embodied, from PRX and WUNC. I’m Anita Rao.
If you grew up like I did – with a gastroenterologist for a dad – you learned early that it’s not just okay… but ENCOURAGED to talk about your poop problems. But unfortunately I’m in the minority.
Trisha Pasricha
Forty percent of Americans struggle with their bowel movements. So that's a huge percentage of people, but think about kind of how few people are having these conversations out in the open and getting help.
Anita Rao
Neurogastroenterologist Dr. Trisha Pasricha and I join forces to bust common poop myths, explain what’s actually normal — and explore the surprising science behind the gut-brain connection.
Trisha Pasricha
One frame shift that everybody needs to make is to think about their gut as a brain. And these two brains are just talking to each other nonstop.
Anita Rao
Your Guide to all things poop and the gut … just ahead on Embodied.
If you've been listening to Embodied for a while, you know that we love a taboo topic. And of course there are some that are more difficult to talk about than others. But luckily for me, one of the subjects that many adults find most uncomfortable, I have absolutely no problem gabbing about, and that is poop.
As the daughter of a gastroenterologist, I was literally raised to report back to my dad about poop problems, and as an adult. I still occasionally text him poop pics if I see something troubling in the toilet. This means that most of my digestive issues get resolved relatively quickly, but I didn't realize how much of an anomaly I was until I read the book. You've been pooping. All wrong. It's written by Tricia Pascha, who is a physician, researcher, and medical journalist, and by page five, my jaw was already on the floor because apparently almost 40% of Americans say digestive troubles disrupt their daily lives, and three out of four Americans won't poop in a public bathroom.
So to help y'all have less poop struggles, we've gotta first get you comfortable talking about it, and that's our mission today. This is Embodied our show about sex, relationships and health. I'm Anita Rao.
Like me, Tricia grew up with a poop doctor for a dad, and her dad is also a neuro gastroenterologist, someone who studies the brain gut connection. We'll deep dive into all the cool brain gut connection research a little later, but first, a view into our poop positive households. So both of our fathers are gastroenterologists and specifically neuro gastroenterologists.
And my first understanding of my dad's research as a kid, I think came when he got his first patent, which was for a device to help people with constipation, practice pooping. But I just called it like. Fake poop. Like I told everyone at school, my dad invented fake poop. What did
Trisha Pasricha
You were the most popular girl in school, I'm sure.
Anita Rao
Exactly, exactly. What did being the daughter of a GI doc mean for your day-to-day life growing up?
Trisha Pasricha
Well, I think one thing I didn't come to realize was abnormal until years later, like got into college, became a gastroenterologist, is that most people don't talk about poop at the dinner table.
Anita Rao
Yeah.
Trisha Pasricha
And it was like every morning, you know, like I think some. Dad. Some families are like, so what? You know, what'd you do in school today? Like, what's your homework looking like? Did you make friends? It was like, did you have a bowel movement this morning? Did you poop this morning? And it was like, these kinds of questions were not like, it wasn't like an interrogation, it was just like a, did you have a good day today? Meaning did you poop? And like these were the kinds of questions that we asked. It was like a friendly check-in. Turns out a lot of people don't get that kind of friendly check-in from their parents growing up, like every day. But you know, one of the things that he tried to. Teach us from a young age was just that you'll not be as happy as you can be in life if you're not having normal bowel movements. You know, and, and it's like funny that both of our fathers probably grew up in, in my dad grew up in India, and people's bowel habits there are very different than the bowel habits here in the us. Yes, we can talk a lot about that. But the typical American, the statistic is that 40% of Americans struggle with their bowel movements, like meaning their bowel movements interfere with their daily activities. Every day. So that's a huge percentage of people, but think about kind of how few people are having these conversations out in the open and getting help.
Anita Rao
It's funny too, because I'm thinking about, like one of the things that was really different in my household was. Poops and farting were still funny, but like we weren't allowed to joke about them. Like, it wasn't like, like, and my best friends love to tell a story about coming to our house and someone like accidentally letting out a fart around the dinner table. And like everyone is looking at each other. And my dad is like, very good, very good. You can't, you can't shame them. Like there's no shame or silence around this. Like, was that how it was even when friends came over for you?
Trisha Pasricha
Oh my God. I love that story. And also, it's funny because that is exactly what I do with my kids. Yeah. Is, you know, I think it starts at such a young age that we stigmatize anything related to our GI tract, including farting, which, yeah, don't get me wrong, I think like I love a good fart joke. I thought it was funny like everyone else, but when, like when my kids, oh, I have a 2-year-old and a 4-year-old. If they fart, they call it tooting, which is I think is. So cute when they have like a little toot. I'm like, good job grandma. Good toot. Like I, I'm not like, oh, who did it? Who's gonna fess up? Like it's this crime that someone has to own. Like we just own it and we applaud each other. And I think that we sort of wanna start early to not make people feel so embarrassed and ashamed.
Anita Rao
So we grew up in these really poop positive environments, but our paths did diverge. I knew when I was pretty young that I didn't wanna be a doctor. I was kind of squeamish around some medical things. But it seems like you had the opposite reaction. When did you first know that you wanted to become a physician?
Trisha Pasricha
When I was younger, one of the first memories I have, like was going to this day at my, I think it was like my elementary school or something, and like where we had to share what our dads did for a living. It was like this like parent career day. And I was trying, having been prepped really thoroughly by my dad to explain that he had discovered this cure for this disease called achalasia, which you can just, Ima a 4-year-old is not gonna get that word out properly. Like much less like be able to convincingly like tell. Any other 4-year-old why this matters who it was. But like I totally bungled like what he had done. But what I caught from him was that excitement he had about having spent years doing this research, finding a cure for a disease that a lot of people have been suffering with for a long time until that point and did not found a good treatment for. And it was that spark when he was talking about his research that really like changed something for me because. I think what separates the neuro gastroenterologist a little bit, they, they focus on diseases because it's a relatively newer field that there hadn't been a lot of therapies for, for a really long time. There hadn't been a good understanding. Probably anyone who's listening knows that irritable bowel syndrome comes with a lot of confusion. Patients often feel like when you get told you have IBS, it means that. We don't really know what's going on. But to hear my dad talk about his joy and excitement in wanting to be part of the movement that would understand these diseases, that's what really motivated me.
Anita Rao
So you started your own science career pretty early on. You even conducted a brain gut experiment in high school that won you second place at an international science fair. Tell me about that experiment and what you discovered.
Trisha Pasricha
Yeah, so the other side of my story is that, so my dad is this neuro gastroenterologist. My mom, when I was growing up, she had been an engineer with the FBI and I. If anything, I thought her job was even cooler. And so one of the things she used to talk about were lie detector tests and how difficult it was to develop an accurate lie detector test because spies had come up with all these ways to override. For example, you could. Step on attack in your shoe to spike your heart rate every time you got asked a question. And that way, like the person reading the the lie detector test wouldn't be able to know when is your heart rate up because you're lying. When is it heart up? Just because it seems like it's up all the time. But one thing that she realized and she passed on to me is that nobody could figure out. That sinking feeling we get in our stomachs when we're caught telling a lie around the same time like that. We were hearing that conversation and my mom was telling us about this. My dad, one of the projects he was working on was for this condition called gastroparesis where the stomach doesn't empty correctly. And he was using this device called an electro gastro, which is very similar to an electrocardiogram, but it measures the electrical rhythm of the stomach. And that was like my light bulb moment at the dinner table because I was like, okay, people use EKGs heart rate monitors as a lie detector. What if the sinking feeling we get in our stomach, the butterflies, the nervousness? What if that could be captured by an electro gastro? It took several years by the time I was in high school to have recruited patients, to have sort of figured out what the right model would be and get approval through all the irb, all these things. And as it turns out that when we tell a lie. You do get an abnormal rhythm of your stomach, so that electrical activity, the stomach usually contracts it three cycles per minute. It goes into chaos when you're telling a lie. Mm, when you're nervous, when you're stressed. And it was really cool because that's something that at least so far, knock on wood, like people haven't figured out a way around it. What I learned more from that experience was how much there is still to be learned and, and how much we don't understand about the gut-brain connection.
Anita Rao
So we have you in high school, super precocious, you're getting your own IRB done. You are leading your own experiments, you're recruiting your own patients. Then you go to medical school, then you do an internal medicine residency program at Johns Hopkins, which meant that you were actually at the same hospital where your dad was working and doing research and. I am so fascinated by the, the idea that you have had been able to watch his career up close, and you had this kind of early experience of realizing that some of the people who were your fellow students had a response to the kind of patients that your dad was seeing, maybe felt a way about treating patients with complicated GI issues. Can you tell me that story?
Trisha Pasricha
Most of what I knew about patients with neuro GI disorders like IBS was all like really wonderfully through the lens of my own father, and I was really, the only word for it is, is just like disappointed and a little surprised that most people, or many people that I encountered did not view these patients with the same degree of optimism. And enthusiasm that, that my dad always had. And the way the, the reason is this, that patients who have these. Diagnoses. Maybe it's functional DYS Pepsi, maybe it's irritable bowel syndrome, that we don't quite have a clear algorithm for how to treat. We don't quite have all the data at hand for what exactly is going on. It takes a lot of training to get there. It's very frustrating to be the doctor. Mm. To feel helpless, to feel like you don't know how to treat them. And, and I think the concerning thing I started to notice is that people seem to be transforming that feeling of helplessness into upset toward the patient. I had co-residents who would say, oh gosh, it's one of Dr. P's patients coming in again, and they were just sort of groan because it was like. Oh no, this is gonna be very difficult to treat. And you know, we don't know how to do it and it's almost like they blamed maybe my father for these patients kind of even coming in to seek care in the first place. And, um, that was like probably my biggest moment of reckoning where I was like, maybe I don't wanna go into this field. Um, not because there isn't a big need, but because. People don't view these patients the same way I thought we all did, and I'm lucky my dad was in that institution with me and like he just was so unbothered by what the world had to say. All he cared about was like, how are the patients doing? And what are the next kinds of innovative ideas we can come up with that people haven't thought of? But he really made me think apart about why I wanted to do what I wanted to do and ultimately. I wanted to actually help a population that needed help so desperately.
Anita Rao
Just ahead. We'll break down common poop myths and learn how to decode what's normal and what's not. You're listening to Embodied from W-U-N-C-A broadcast service of the University of North Carolina at Chapel Hill. You can also hear Embodied as a podcast. Follow and subscribe on your platform of choice. We'll be right back.
This is Embodied. I'm Anita Rao. For some people, poop is the last thing on their mind until it becomes the only thing they can think about. I'm talking about that. Oh, no. Feeling you get waiting in a too long security line or being miles into a run with no bathroom sight. But digestive distress is common, and as we've been talking about. A big part of the problem is that many folks lack even basic knowledge about poop. So today we're going over the fundamentals with neuro gastroenterologist, Dr. Trisha Pasricha. Welcome to Poop Basics 1 0 1.
I wanna start with a rapid fire round just to get some basics laid down if you're down for that, and then we'll go a little bit deeper into some other pieces.
Trisha Pasricha
Yeah, let's do it.
Anita Rao
Okay. So first, what is poop?
Trisha Pasricha
Poop is partially the undigested bits of whatever you've eaten, but it is mostly, if we're talking about mass, it's mostly your microbes, your gut microbes.
Anita Rao
So cool. Okay. What colors of poop are normal?
Trisha Pasricha
Most shades of brown would be considered within the range of normal, but you'd be surprised. I get so many messages every month of, and I get pictures too, so I like, I get the full receipts like, of like, what is this? A weird color poop. And it'll just be like a kind of interesting shade of yellow or like maybe they'll be a little bit green. It'll be like a nice like kind of purpleish shape. Every now and then we are all allowed to have like a weird colored poop that doesn't have to mean anything profound. And the colors that I think we need to be really worried about are shades of red. So shades of red to me can indicate bleeding. Dark tarry, black stools. Like anything that's sticky and like pitch black. Like I, I usually, when I'm telling my patients, I'm like, it needs to be like the color of your phone screen when it's off. Mm. Like just really dark brown. That's not gonna excite me, but like, black, black, that could be blood. Um, and then pale colored stools, like the color of clay. If you see that white color, that beige color, it means something is blocking the bile from reaching your stool. That's an emergency.
Anita Rao
How often should we be pooping?
Trisha Pasricha
That is the age old question. He, we, people have been asking this question since the dawn of time, and we have it in our heads that we should be pooping once a day. You do not. I, this is like something like a mantra. I try to tell with my kids like, you do not have to poop once a day. Everyone thinks that there's just like one path to God here, and you could poop multiple times a day. You could poop. Once every other day. Every three days. And so they've done this big survey, like a national survey of Americans and people who think that they have normal bowel patterns. They tend to say that their bowel movements fall between once every three days as frequently as that to three times a day. So that's a huge range of what people would consider normal.
Anita Rao
Okay. So you, we've talked about the different colors of poop. We've talked about how often we should poop. And now we've gotta talk about the shape of poop. There is a scale that is called the Bristol Stool Form Scale. It was developed in the nineties in England. It describes the seven categories of human poop. And I'm not even kidding you. For my dad's 50th birthday, he had a Bristol stool scale made out of icing on his birthday cake.
Trisha Pasricha
What? Who did that? That's amazing.
Anita Rao
I know. Did you guys do that? No, we had like a local baker do it. I've asked my mom to dig up a photo because I feel like we need to share it with this episode, but he also has like a, an apron with a Bristol stool chart, t-shirts. So I have seen this chart, um, many times in many forms, but a lot of people haven't. So for the people who have not seen it represented, describe what it is and, uh, a way that we can conceptualize it.
Trisha Pasricha
Wait, there are people who haven't seen the Bristol.
Anita Rao
Yeah. Apparently people don't have it on their birthday cake. I dunno.
Trisha Pasricha
Um, that's amazing. Your dad is a legend. Um, so the Bristol Stones Club, you are right. So it was developed in Bristol, England, and the way it worked was, um, this doctor's name was Dr. Kenneth Heaton. He actually went around to the local community members in, in this town of Bristol and just survey them, almost 1900 of them, about their pooping habits. And what he found was that. The appearance of your poop actually correlated really nicely with how long it took that poop to travel through the length of the colon. So the scale goes from like a type one all the way down to type seven, type one. Are these like small hard lumps, they look like little rabbit pellets. And then as you move down the scale, you start to get more of that like smooth sausage like appearance. That's a type four. And then you get all the way down to the end, which is type seven. And that's like super watery, no formed pieces. Nobody enjoys a type one or a type seven. Everyone's aiming for that type four. But it's a great, it's a great form that we actually use in clinic a lot where we just say, where do you fall on that scale? Because it actually gives us a quick picture of how quickly things are moving through your body.
Anita Rao
Hmm, okay. So it's not necessarily like you need to aim for a four, but whatever it is along that scale, it could be telling us about something that's happening in the GI tract.
Trisha Pasricha
Yeah. A type four. I feel like on social media, I'm seeing a lot of people like write or post about this thing called a ghost poop. Have you heard about this?
Anita Rao
Yeah, of course. Yeah. Of course. Everyone wants a ghost poop of,
Trisha Pasricha
Yeah, exactly right. It's this poop that, and I've heard different definitions. The way I understand it, I'd love to hear if you've, if you've heard otherwise, but the way I understand it is you poop you. It's like beautiful formed. It sinks to the bottom. It's a weightless wonder, white wonder. That's how I have it. Didn't have it.
Anita Rao
Yeah.
Trisha Pasricha
Yes. So that's type four. And yeah, it is like kind of a heavenly poop. I don't know that like if you, if you're always a type five, A type six, that you're any less healthy than a type four, because there is gonna be a little bit more of a fluffier poop when you're meeting your fiber goals. That's like the caveat I'd say. But I've also like, on either end of the spectrum, it can kind of help people realize if I'm living in type one, which are these like little rabbit pellets. Mm. I've never met anybody who has consistently had type one stools who enjoyed that poop. Nobody likes that. Everyone feels like they didn't get everything out. They, you probably had to strain a lot. So if you're on the extremes, I think we do have a problem. We need to talk about it. If you live somewhere in the middle. You're probably okay. And if you do live at type four, look at Congratulations.
Anita Rao
You are a medal winner in our book type fours. Okay. So I knew, yeah, I definitely knew some things about poop before reading your book, but I learned a lot, especially from some of the metaphors that you offer for thinking about gut health, especially the toothpaste metaphor. So can you tell me a little bit about that and what you're trying to explain with the toothpaste metaphor?
Trisha Pasricha
Yeah, so if you think about getting toothpaste out of a tube of toothpaste, you can try to squeeze that toothpaste tube really hard, and I think about that as the propulsion, and I call this framework the three Ps. So there'll be three, three Ps coming up. So propulsion is sort of the squeezing of the toothpaste tube. There's also the consistency of the toothpaste itself, right? So if you, it's like a 10-year-old tube of toothpaste and it's rock solid, you can squeeze as hard as you want. That toothpaste, if it's like a rock, it's not gonna come out. That's the pliability. And sometimes I think these like things that we think of as laxatives, like fiber maybe is, or, or MiraLax, just thinking it over the counter. Those are often aimed at improving the pliability of the stool. But the most underrated, underappreciated pee here is the pelvic floor and about a third of people who struggle with constipation and they've tried different things, but they, like nothing seems to work. The issue is actually the pelvic floor, and, and I think of that as like you forgot to take the cap off the toothpaste. Hmm. You can squeeze as hard as you want. That is the softest toothpaste you've ever seen in your life. But it's not gonna come out because the cap's on and well, we don't appreciate the pelvic floor. It's more than a dozen muscles that all have to coordinate in this really beautiful dance of, some are contracting, some are relaxing. And it's very counterintuitive because when we have a bowel movement, all of us strain for just a second, we bear down, we do this valsalva Maneuver. We actually need our sphincters, our anal sphincters to relax, to open up so something can pass through.
Anita Rao
Yeah. My dad has been on the show before talking about some of his work, understanding pelvic floor dysfunction and helping people with it. But the thing is, it's not like it's, that's not super easy to get support around. So talk to me about, you know, people who might realize like, okay, maybe it's the third p, the pelvic floor. That is the problem. Like what are the interventions that are available for people who need that kind of support?
Trisha Pasricha
Yeah, you're, you're absolutely right. One in three people who have struggled with constipation and have failed laxatives. It's, it's the pelvic floor, so it is like pretty common. The treatment for it is pelvic floor physical therapy, a special kind of physical therapy called biofeedback, and it's biofeedback that your dad has studied and several others that really shows. Good data, like 80 to 90% of people who have pelvic floor dysfunction get better after just a couple of weeks of retraining. Like eight to 12 weeks is, is the range. The problem is that pelvic floor, physical therapists who do the biofeedback, they're not, you know, they're like not easy to come by in a lot of parts of the country and. Sometimes there's another barrier, which is that we often make the diagnosis with this test called an anal rectal manometry, which is a very exciting sounding test. And I try to tell people, this is just a weird test, okay? It's not an, it's not painful. We basically put a small balloon in your bum. And that has pressure sensors all around it. And then you try to push that balloon out and as you do so, the pressure sensors on the balloon can tell us, okay, are you generating enough pressure in your rectum? Are the muscles that are supposed to relax actually relax? And it gives us a lot of information. But the limitation of all of this is that, yeah, we need more people to become trained in the techniques and we need it to reach other parts of the country that are not like major cities.
Anita Rao
What's so interesting in like learning more about. Ideal pooping form and and pooping posture is that so much of our western way of life really works against our body's natural. Preferences. And my dad always jokes that he missed his billionaire moment by not branding the Squatty potty because he had been telling us since we were little to like put a stool under your feet to poop. Like you need to elevate your feet. Yes. To help things move more quickly. So talk to me about this kind of Western way that we sit to poop and why that's not super ideal for our bodies.
Trisha Pasricha
Yeah, so we have been squatting for most of like the history of humankind, meaning like we'd like get down on our haunches, and if you think about the colon as a long tube, towards the very end, there's this muscle that goes around the tube of the cho and kind of chokes it shut like a sling when we squat. That muscle is able to relax and open up so that the tube of our colon is straight again and the poop can come out. But when we're not squatting, when we're sitting kind of at that 90 degree chair angle, which is what all of us do now, we actually are not opening up the tube as cleanly as and patently as we could. So a simple fix is to just use a stool. And I, I've, I feel for your dad could've been a billionaire with this idea, but I also tell my patients, you know, you don't actually need to buy any branded stool. Like use whatever. Use a stack of books, use a pair of high heels, like whatever you got going on, but just lift the knees above the angle of the waist. So it's not practical to tell people to squat, but I think what everybody can do is get that stool in there to kind of like. Get back a little bit more of that natural physiology that we once really leaned into.
Anita Rao
So there's one other kind of piece of our western way of life that I wanna ask you about, which is how we kind of work against our colon's natural rhythm. So our colons have their own circadian rhythm. That's so wild to me. Tell me about that and, and kind of when they want us. To be pooping.
Trisha Pasricha
Yeah, I know. Isn't that wild to think about?
Anita Rao
So wild.
Trisha Pasricha
So many of our organs are kidneys, for example, like we often wake up in the middle of the night to pee. We almost never wake up in the middle of the night to poop. And if you do, there's a problem, like you have norovirus, you have like inflammatory, but like there is something else going on. Well, why is that? And it's because the kidney is just constantly working. Like it doesn't stop just because you've gone to sleep, but your colon is actually interestingly operating on a very similar circadian rhythm to your brain to the rest of your body. And so. It too becomes pretty quiescent when you go to sleep at night and then when you wake up it really buzzes with activity. And I actually do think that this is the reason why that like early myth of like, you need to poop once a day in the morning. I think this is how it got started because there is certainly a valid reason why we're primed to poop in the morning. Your colon is more active. In the first one or two hours upon waking, then it's gonna be almost the rest of the day. And then there's things that you can do later on that can kind of reactivate it so exercise can get it moving again, coffee, these things can stimulate the colon again. And so when somebody's trying to, who comes to me and they're really struggling with their bowel movements, sometimes I say we need to just kind of have a regimented schedule and train it just like we would anything else and say like, let's schedule the bathroom. Let's go for a quick walk with the dog. Let's have our cup of coffee and then let's try, and the colon can become trained. But it's like so helpful if you try to go when your body wants you to go, because if. You go and your colon's doing that work. It's active, it's pushing, it's giving you the extra propulsion. It means you have to generate less pressure with your Valsalva maneuver. You have to strain less. If you try to go in the afternoon when your colon is kind of laying low, then you have to do all of the straining yourself to get that same amount of pressure. So understanding the physiology and the timing of how our colons are active in the morning can actually use less work for you, and it can make the pooping experience a lot more fun.
Anita Rao
So that sounds ideal. And then literally what happened to me this morning is like I'm rushing to get out the door. I have my first cup of tea when I get to work. I'm finishing my breakfast and my snack and uhoh. It's nine 30. I need to poop. And the only available option in our building is a multi stall.
Trisha Pasricha
The worst, the worst.
Anita Rao
Luckily, I have no shame and I like, I have no problem pooping in this environment, but that's not true for most people. So like, talk to me about what we do then. Like we now we have the urge to go. Our colon is active, but we're not at home. We're not in a private place. What do we do?
Trisha Pasricha
Well, first of all, you're not alone. Like most people would hate to go in public. Nobody, I don't think anyone loves going in a public stall, especially with this like constant thread of like, is someone gonna sit down in the stall next to me? Are they gonna hear what's going on? Like, are they gonna judge? Are they gonna smell? God forbid, that's the worst. However, I do tell people when your body calls, you have to listen. Because it's our instinct to say, no, no, no. This is not a good time for me. I'm gonna like, let's do this When we get home, when you get home, your body is not ready for it. That urge to go is your colon and contracting. That's what gives you that sense of urgency and like, oh my gosh, I need to do this. Now. When your colon's not contracting, which it won't be later, that means again, you have to strain in order to get it out. But the second piece is that. Your colon's, like one of its biggest jobs, is to absorb water out of your stool. It's doing that 24 7. It's just constantly sucking water out and putting it back into your bloodstream. So 12 hours later, you've given your colon 12 more hours to suck that poop dry. It's gonna be a different poop than the one you had at nine 30 in the morning. You haven't done yourself a favor by waiting, whereas if you'd just gone when it responded. You might have been able to get it out in a minute and move on with your life.
Anita Rao
You could have had a ghost poop.
Trisha Pasricha
You could, you missed your chance at a ghost poop. And those are just, they're beautiful when they come. You can't turn those down.
Anita Rao
Okay, so we have talked about how to get our poop out. So now we have to talk about wiping. And I love that you dedicated a whole chapter of your book to wiping because nobody. Nobody talks about this. And I was sharing some findings from your book with my partner and he literally was like, no one has talked to me about pooping since I was three years old or about wiping. No one has talked to me about wiping since I was three years old. Like, why are you trying to talk to me about how I wipe my butt?
Trisha Pasricha
Yes.
Anita Rao
So like we don't talk about wiping really.
Trisha Pasricha
Yeah. Well let me ask you this, 'cause I do think this is like something that gets in between a lot of relationships. Are you a one ply or a two ply kind of family?
Anita Rao
Yeah, so two ply definitely. But there's only one ply at work and it's such a shame.
Trisha Pasricha
It's so devastating. You deserve two ply two. Like everyone deserves two ply. One ply is harsh, it's abrasive. It's like an act of self care to use two-ply toilet paper. But as you probably saw in that chapter, I actually don't really advocate for toilet paper at all. I'm a I'm team bidet.
Anita Rao
You are.
Trisha Pasricha
I'm bidet all the way.
Anita Rao
You are.
Trisha Pasricha
Yeah.
Anita Rao
So tell me more about your affiliation for Bidets.
Trisha Pasricha
Yes, it's deep and I recognize that a lot of people are just not used to trying new things back there. This seems super weird, but I'm gonna just tell you a little bit of the mechanics. A bidet is basically just this. It can be a nozzle attachment or it can be the whole seat of the toilet that you replace, but all it is is a spray of water. It's a spray of water that cleans up your bum after you're done, and then you can either pad it dry with a towel or some of the like really fancy like toilet models, have like an air dryer. Then you're done. That's all it is. It is external use only. It's a separate nozzle that is a separate water supply, so there's like no risk of anything contaminated touching you, and it's very clean. It's like warm. It's lovely. You can get a seat that that's heated, which I live in Boston. It's like the most glorious thing in the world. Why would you say no to that?
Anita Rao
And if you're going to wipe, if you're still afraid of the bidet, you vote to dab instead of aggressive wiping because that skin is so delicate and thin, important to dab and kind of be gentle.
Trisha Pasricha
Yeah, I mean, I think if you're in a situation where you're like, you feel you need to do an a lot more aggressive wipe, then you probably have entered bidet territory anyway, my friend. And then we should think about whether toilet paper even makes sense at all.
Anita Rao
So with all of this in mind, I wanna ask for kind of a general rule of thumb of how folks should know if they need to see a doctor to talk about a pooping issue. They may now have a sense of a, a range of normal, but how do you know when that rises to, okay, I should make an appointment with a gastroenterologist?
Trisha Pasricha
Well, I would say that. Almost any concern, you should just talk, like just run it by your provider. So I have a really low threshold. I think if we're talking about what is the most. Concerning sign, like when you should see a doctor and you should see them like soon. It would be anything that involves seeing blood in your stool and anything involving pain. Like if you have new abdominal pain. One thing, um, that I worry about often I think every gastroenterologist worries about is this rise of colorectal cancer cases among younger people. And blood in the stool is often the earliest sign. Um, it can be pain, it can be iron deficiency, anemia. We don't wanna just say that's hemorrhoids unless somebody's. Confirm that and a doctor is confirmed. Um, and if we need to rule out something else, then we should.
Anita Rao
Just ahead, we will explore what we know about the brain gut connection and what new research is helping to reveal, like how Parkinson's might actually start in the gut. Stay with us.
This is Embodied. I'm Anita Rao. Your gut isn't just where digestion happens. It's lined with more than 100 million nerve cells that constantly send and receive signals to your brain. That back and forth conversation influences everything from how you feel to how you experience stress, pain, and even emotion.
Trisha Pasricha
I think one frame shift that everybody needs to make is to think about their gut as a brain.
Anita Rao
To continue our poop conversation, we're diving into the science behind the gut brain connection with Neuro gastroenterologist, Dr. Trisha Pasricha. She wrote the book, you've Been Pooping All Wrong.
Trisha Pasricha
So we all know that we have this brain in our head, which is really a network of nerve cells that are connected to each other and signaling to each other and producing these. Molecules called neurotransmitters, right? Like we've heard of dopamine and serotonin. Well, it turns out your gut has a brain that does very similar things, and we call the brain in the head the central nervous system, and we call the brain in our gut the enteric nervous system. And so eventually there was a very strong and important connection that was developed between the brain in our head and the brain in our gut. And that's the vagus nerve. And that's where most of the communication happens back and forth. And the signals they're sending are. Two ways. In fact, 90% of the signaling on the vagus nerve is going from the gut to the brain, not the brain downwards. And the gut is taking all the information that it gets from the outside world. So all the food that you throw in there, all the chemicals, the so-called toxins, anything microplastics, all of these things that are coming into your body and then interacting with the gut microbiome, and the gut microbiome itself responds to what you. Give it to eat and it produces new metabolites, like short chain fatty acids that can then be absorbed into the bloodstream or that can signal it back up through the vagus nerve. So it's taking all of this information about what's going on in the outside world and that you're bringing inward and it's sending that information back up to the brain. And then the brain in turn is taking information about things that it's perceiving about the environment, things that you see, that you smell. One of the first sort of even parts of digestion. It doesn't start in the stomach. The first stage of digestion is called the cephalic phase, and cephalic means head in Latin. And that's because even thinking about food, just the thought of this luscious chocolate cake can make you start to salivate. It can make those digestive juices start to ree because you're anticipating eating. So even your thoughts are shaping directly what your gut is doing. And sometimes, like I learned with my. Science fair project in high school. Sometimes it's emotion, sometimes it's fear and anxiety that can cause changes in how your gut is moving. And all of that information goes back and forth. And then there's a feedback like your brain in the head responds to that information. Then maybe it say, you know what? We need to calm things down. We need to slow it down and and vi vice versa. So it's kind of this constant loop, a lot of which is happening without you consciously processing that these two brains are just talking to each other nonstop.
Anita Rao
So there's so much that we're beginning to understand about this feedback loop. As you said, we now know that 90% of the gut brain traffic travels from the gut to the brain. There's been a lot more focus on this, and one piece that you've been looking into in particular is related to Parkinson's disease. Tell us about what we have begun to understand about how our gut may be influencing Parkinson's.
Trisha Pasricha
Yeah, so I run a laboratory that's funded by the NIH to study Parkinson's disease. And like usually when I tell people that, they're like, wait, aren't you a. Gut doctor, like, what do you have to do with Parkinson's disease? And this is what, what it is. When I started my practice after fellowship, I started seeing a lot of patients with Parkinson's Disease who were coming because they had severe GI symptoms. Like they would say, if I could trade away any one of my symptoms. It wouldn't be the tremors, it wouldn't be the difficulty walking. It would be my constipation. Hmm. And I would hear that pattern over and over again. And as it turns out, about 80% of Parkinson's patients do have at least one GI symptom. Maybe it's nausea, maybe it's constipation. But the more digging I did, the more I found that. Not only do they have these GI symptoms, but people had found that the GI symptoms tend to precede the onset of the tremors or of the other motor symptoms that we associate with Parkinson's disease. So like even by 10 or 20 years, people would get constipation maybe in their forties or their fifties, and then later, eventually they would become diagnosed with Parkinson's disease. And in the 1990s, researchers began to develop this hypothesis that. Parkinson's might start outside of the brain. So we now have a good body of evidence that says some portion of patients with Parkinson's disease. The disease starts in the brain, but there's a good percentage that it probably starts somewhere in the body. And one of those sites is the gut. And the ways that we know this are one, if you do autopsies of patients with Parkinson's disease. In Parkinson's, there's an abnormal protein called alpha synuclein that can misfold, and when it misfolds, it can cause damage to the nerve cells around it and, and famously it can kill off these dopamine neurons that are in the brain. And that's how we get this, the classic symptoms of Parkinson's, or at least that's the idea. If you do autopsies on these patients with Parkinson's disease, you would find that their enteric nervous system is riddled with misfolded alphas to nucle and. It's been there before it reaches the brain and the idea is that some trigger, and we don't quite know exactly what that is yet. Maybe it's an infection, maybe it's some chemical, maybe it's pesticides have been talked a lot about something in our outside environment. Some trigger causes alpha-synuclein to misfold. In the gut, and then it travels up the vagus nerve and it reaches the brain. And that process takes several years. Now what's interesting is that if you believe that hypothesis to be true, then you would say, well, if I cut the vagus nerve, wouldn't that prevent Parkinson's disease from happening? And as it turns out, we actually did cut the vagus nerve of lots of people back in the 1970s and around that era to help treat severe peptic ulcer disease or to help. Treat severe acid reflux. 'cause it was in the days before we had medications called proton pump inhibitors, which helps suppress acid. So we don't really do that procedure anymore surgically where we cut the vagus nerve because now we have a pill that does the same thing, only way, way better, and doesn't come with all of these risks. But what it gave us is this opportunity to study thousands of people who underwent that procedure and it turns out. If you look at all those people who had what's called a vagotomy, so surgically cut the vagus nerve, they also cut their risk of getting Parkinson's disease by about half.
Anita Rao
Wow. So I'm thinking in hearing you say that, that you know better understanding of the gut brain connection, better understanding of what are the changes that are happening in the gut that might be signaling things to the brain, could have implications for. Other neurodegenerative diseases. I'm thinking Alzheimer's. It, it seems like this could potentially be a big field of study.
Trisha Pasricha
Huge field. I mean, probably Parkinson's is. And there's still so much to learn, but it's the one where we have the most information and, and we still don't know as much as we wanna know, but we're certainly seeing similar patterns in Alzheimer's. So there was a big study that was done that showed all of these different GI symptoms, something called gastroparesis, which I've mentioned before, where the stomach empty slowly, or constipation, these things. Earlier in life can predict the development of Parkinson's. Well, it turns out they also predict Alzheimer's. Now, just to be so very clear, having constipation doesn't mean you're gonna get Parkinson's or Alzheimer's. 'cause we all have constipation like so, and in all this they're not gonna get that. But we need to know more and, and it's other neurological disorders too. Huntington's disease, even autism. There's a big gut-brain connection that we're all kind of working on trying to elucidate a little bit better.
Anita Rao
So we've been talking about this field of neuro gastroenterology throughout this conversation and we started with that early story of your experience, kind of hearing people talk about your dad's patients as folks who were really complicated and sometimes maybe too complicated to study and spend time with and, and it made me think about how. Growing up, I would see, like my dad had patients that were traveling from around the country to stay for such long stints in Iowa that like we'd have them over for dinner. And like, I know that sounds really weird to a lot of people, but like we got to know his patients well because what they were dealing with was so complicated. It took a really long time to unravel and do all the right tests. Yes. And the stuff that they were dealing with was so emotional. And I wanna talk about that. Yeah. Emotional piece because there is a level of. Stress and kind of deep psychological trauma that a lot of folks who have these complicated gut issues are dealing with, and I would love for you to talk a little bit about that and how Neuro Gastroenterology has helped us maybe treat these folks with more compassion and not be so dismissive.
Trisha Pasricha
I think the heart of neuro gastroenterology and so, so many of my patients come to me and after we meet, we go through everything they've been dealing with and we do some history with say, I'm able to do, you know, come up with this plan of, maybe it's more testing, maybe it's certain therapies. They often say You're the first person who hasn't told me. It's all in my head. And that is so hard to hear. It's such a relief. When a patient meets a doctor who believes them, and it's also like the bare minimum thing any doctor should do is just believe your, like if you start with a foundation of, I'm gonna believe my patients, it actually opens up. The door for a lot of innovative thinking. If you start by saying, I think my patient's making this up. I think this is purely psychological. You're gonna shut the door to all of the therapies that could target the gut, that could say, wait, there's a real problem that originated in the gut. And the problem is that, of course, if you have a problem, whether it originated in the gut or not. You meet doctor, after doctor, after doctor who tells you this is all in your head. Of course it's gonna fuel your anxiety and your depression even more, and it's gonna make you very wary of the medical system. And one thing we know to be true, which I often share with patients, like I said at the beginning. We don't have good tests in clinical practice that can show people the abnormalities in something like irritable bowel syndrome or or other diagnoses. But we have those tests in research, which is how we know they're not. Making it up, which is why it's so easy for us in neuro gastroenterology to believe our patients because we know what the abnormalities are. And so one of them, I'll give you an example. We know that people who have irritable bowel syndrome, if you did a stain for a certain type of pain nerve cell in the colon, you would find that those cells. Are more common. So these people respond to pain more commonly and at a lower threshold than people who don't have irritable bowel syndrome. So it's not just that they're sensitive people, it's not just that they have depression or anxiety. Their nerve cells are fundamentally different. In their colon. So a primary problem is happening at the level of the enteric nervous system and sometimes just saying, this is something we know to be true. There's big studies on it that can really like shift people's thinking and, and make them feel heard. We just don't do that stain that test in in every day. But now take a situation where you have a patient who we know has this abnormality. We know those nerve cells that perceive and respond to pain are firing more commonly, more frequently than everybody else. You're gonna live in a state of feeling constantly triggered. You're gonna become hypervigilant, wondering, is this thing I'm going to eat gonna set me off? And you're gonna become more and more anxious because you're truly feeling more signals coming from your gut. The problem is then you meet a doctor or you meet someone in the healthcare system who hasn't done those stains, is not familiar with the research, and all they're seeing is you seemingly very stressed about symptoms. Having a perfectly normal colon, as far as they can tell, they're gonna tell you. The problem is you're worrying too much about it, and they will have in fact missed the entire problem. But they're gonna say it's all in your head because that's what it seems like.
Anita Rao
So we've been talking so much about the work that you do as a physician and the importance of this. Physician patient connection, but I'm thinking about this moment that we're living in where healthcare is so, so expensive. More expensive now than ever. It is so hard to get an appointment with a doctor. Yeah. And when you do get an appointment, you see them for six minutes and so like it is, as someone who grew up in a family of doctors who believes in medicine, I also have a lot of compassion for my friends who are like. I'm just gonna Google it. Like I don't have the time and the money. And I know this is something that you think a lot about, so I'm curious about like how we can engage people who wanna be, you know, proactive in their gut health. Who, who feel like, yeah, I should care about my poop because it's important to have good digestion, but also I can't afford, or I don't know how to make time to do. Some of the stuff that you all are laying out.
Trisha Pasricha
Gosh, yeah. This is a problem I wish I knew how to fix. I think in writing my column my, which I write for the Washington Post, it's called the Ask After Column. My goal was to be able to give people the tools to ask the right question so that they walk into their appointment short. Though it may be. Not as frequent as it should be. Like targeted and ready to go to ask exactly what they need to ask about because for example, they've heard about biofeedback therapy for the first time and they just, that hadn't been on their radar, and maybe it's not even on their doctor's radar until they bring it up. I'll also say like, I think the most important. Thing that I learned is that, you know, you have to have a doctor who believes you. And if I, it's very common that people just find that they're stuck in a relationship with a doctor, but that it has to be a two-way relationship. And so you have to like them and they have to believe you. And if that's not the case, I will always empower people to try to find another doctor and, and find somebody who's gonna advocate for you.
Anita Rao
So. If folks are maybe at a phase of their life where they haven't had any of the issues that we've talked about, pooping has been pretty smooth sailing for them so far. Why should we still care and talk about poop? Like what is your argument for why, why poop is so important?
Trisha Pasricha
Well, I will and, and this, not to sound like too pessimistic, but constipation comes for us all. It's just part and parcel of aging. That's how the, the aging gut works. But if you prime the gut earlier in life, it's like most diseases that we've been studying, like for example, we've been finding in Parkinson's disease, Parkinson's disease doesn't start necessarily in your seventies. The groundwork begins to get laid in your thirties, forties, fifties, at a time in your life where you probably feel healthy. You may not feel that you have any issues at all, and you, and perhaps you don't, but you can optimize what the next several decades of your life are gonna look like by treating your gut correctly. And if you think about your gut as a brain. You would treat it as the most precious organ in your body at the age of 20 or the age of 70. I don't care how old you are. If you're going for a bike ride in the middle of the city, you're gonna wear a helmet because you are not gonna play around with the brain in your head. Right. And yet in our twenties and thirties. We often don't treat our gut with that same level of respect and care. We'll, you know, like we'll eat fast food, ultra processed food we'll like neglect to treat it with that same level of care when we should, because our gut is sort of the gateway to our health the rest of our lives.
Anita Rao
Trisha, what a fun conversation. I thank you so much for your book, your stories, and all of your time today. Uh, this has been really fun. Thank you so much.
Trisha Pasricha
Such a pleasure. Thank you, Anita.
Anita Rao
Dr. Trisha Pasricha is the author of You've Been Pooping All Wrong. She's also the Ask a Doctor columnist for the Washington Post. You can find more about her work and research at our website, embodiedwunc.org. You can find all episodes of Embodied the Radio Show there and subscribe to our weekly podcast. Today's episode is produced by Gabriela Glueck and edited by Amanda Magnus. Sara Nics provided editorial guidance and Kaia Findlay is our regular producer. Adesina Newkirk is our intern, and Jenni Lawson, our technical director, Quilla, wrote our theme music. This program is recorded at the American Tobacco Historic District. WUNC is a broadcast service of the University of North Carolina at Chapel Hill. I'm Anita Rao.