What Causes Constipation? – Shocking Facts Behind Constipation | Dr.Ali, Gastroenterologist—-testing

Introduction & Common Myths About Constipation

[00:00] Also, I wanted to bust another myth. Water alone is not necessarily helpful with constipation. 95% of the water in our body is already absorbed in our small bowel. Can you tell our viewers in terms of what is constipation, when should the patient be worried about?

[00:20] People say that okay is it the frequency of the bowel movements or is it the consistency of the stool? Any women having complicated delivery is what you say is when a baby is big and is trying to take them out, they use forceps as a device to get the baby out.

[00:40] So that is why constipation is very common in females. Yeah, absolutely. My sister eats the same amount of food and I'm like 30 pounds heavier than her and even I eat less. So for the longest time we didn't think that that's feasible, but now we understand that it's potentially feasible. In my opinion,

[01:00] In the modern age, we take our cell phones there, watch whatever or text and all that. So we're not supposed to sit on the toilet as much as we sit these days. Definitely does not help with evacuation.

Meet the Expert: Dr. Ali Rezaie & IBS Specialization

[01:20] Hello guys, welcome to another episode of our podcast Gut Feeding with Dr. Pal. I'm very, very excited about this episode. I have a close friend of mine who is an associate professor at UCLA, which is one of the most reputed centers here in the United States. And also, he is also a faculty member at Cedars-Sinai, again,

[01:40] a most reputed center, especially in gastroenterology. His name is Dr. Ali Rezaie and he is the expert in irritable bowel syndrome, IBS. You know, I'm a gastroenterologist, but I see a lot of gastroenterology problems. I see IBS, fatty liver, pancreatic problems, heartburn, you know, over a difficult

[02:00] difficulties in swallowing, colon cancer screening, you know, you name it. I know I'm a jack of all trades kind of thing, and Dr. Dykstra is a master of a single disease, which is irritable bowel syndrome. So, I'm so glad that I was able to bring this expert, and we are going to talk a lot about irritable bowel syndrome, what is constipation, what is diarrhea.

[02:20] what is abdominal bloating, what should one do to prevent having all these diseases and if you have, how do we go about diagnosing and treating? I am excited about this episode. Of course, you know, talking to a colleague with a fellow gastroenterologist is absolutely exciting. I am sure this will be exciting for you as well. Let us dive deep into it.

Gut Bacteria and Its Role in Obesity & Insulin Resistance

[02:40] Hi, Dr. Ali. Hi, thank you for having me and thank you for doing all this and spreading awareness in GI disorders, which not many people do, but it's a very noble cause. Yes. Yes. Yes. People find it embarrassing. I found it enjoyable. But anyway, so thank you for your time. Thank you for your time.

[03:00] time. In my channel, we always talk about gut bacteria, gut bacteria, and I really underline the importance of having good gut bacteria. But being a gut bacteria specialist, expert on microbiome, expert on irritable bowel syndrome, we have been dealing with the obesity pandemic mainly in India as

[03:20] And in my channel they've been focusing on simple preventive techniques to prevent weight gain, decrease insulin resistance. Can you explain to us even in detail about how gut bacteria is linked with insulin resistance and obesity? No, absolutely. I mean, and that's a very active field of research as well. So maybe with the

[03:40] back a little bit to see what we're dealing with when we talk about gut bacteria. So we have about 1 billion bacteria sitting in our mouth per ml. Every cc of our saliva has 1 million bacteria, right? 1 billion. And then as it goes down, it's different types of bacteria with different abundance.

[04:00] meaning that it's not as much. When you go into the stomach, it's less than 100 per ml all of a sudden. And then when you go to the small bowel, it's less than 1000. And all of a sudden, in the colon is 1 trillion bacteria in our colon per ml. If you think about that, there is a gradient of almost 1 million

[04:20] billion times difference in our small bowel versus our large bowel. And all these bacteria do different things and one of the functions that they have is the way they affect that we digest food, the way we respond to insulin and also obesity. Now with specific

Understanding the Gut Microbiome and Its Evolutionary Impact

[04:40] you ask about obesity is interesting because throughout our evolution, the gut bacteria have been with us since our existence. If you go back to the three domains of life, we have bacteria, we have archaea, and we have eukaryotes. Eukaryotes are us of the one

[05:00] ones with actual cells, including fungi, including other animals, including us, and then bacteria and archaea. Funny enough, we're not just eukaryotes. We also have bacteria in our body. We also have archaea in our body. So we are a combination of all three domains of life, which is actually

[05:20] fascinating thing if you think about it. My sister eats the same amount of food and I'm like 30 pounds heavier than her and even I eat less. So for the longest time we didn't think that that's feasible, but now we understand that it's potentially feasible that the same amount of food

[05:40] that two people eat, they can harvest different amounts of energy and calories out of it. So that's where it's coming. So it's a very active field of research. So you did some research on eliminating the diet and then seeing whether there is an increase in the obesity rates. Why don't you talk about that?

[06:00] Yeah, so I mean, there are different types of food that have been associated with different types of gut microbiome. And interestingly enough, archaea are very resilient, if you specifically want to talk about that, and then I'll get to the bacterial part. Archaea can survive on anything.

[06:20] meaning that even on the sloughing of our bowel, remember, the lining of our bowel renews almost every five days. And while those cells die and fall off and new ones grow, that fallen group of cells can be the source of food for those archaea.

[06:40] just survive on that. So it's interesting that even if you're fasting for a long period of time, if you're in ICU, you're not even being fed, right? These archaea can survive. So it's hard to just with diet eradicate or decrease their population, although it is possible and now we can talk about

Elemental Diet and Its Effects on Gut Health & Weight Loss

[07:00] a little bit about the elemental diet that we will talk about. So just by changing the diet here and there, RK are not going to change. So interestingly enough, recently we did a very fascinating study with something called the elemental diet in our

[07:20] So an elemental diet is actually exactly what it sounds like. Food that is just elements. Everything that we eat comes in three main components, right? So it's fat that breaks down into fatty acids or fat droplets in our body, proteins that break down into

[07:40] into amino acids after we digest it and break it down, and also carbohydrates that they break into monosaccharides and then they get absorbed. This process of breaking these big molecules that we eat is essentially digestion. We have enzymes that break it down. Number one, elemental diet has

[08:00] No allergen. Because what are the allergens? All proteins, right? So when you break them down into amino acids, there is no antigenicity, there is no allergic reaction to this diet. And that's actually one of the ways that, for example, elemental diet for babies have a lot of allergies. This is a

[08:20] exactly it. The problem is that the infants don't care what the elemental food or the formula tastes like, adults do. So essentially no food allergies, so essentially no allergens, so you actually go into remission in terms of allergen exposure. Number two, all the food gets

[08:40] at the beginning of your small bowel. Remember, our small bowel is 6 meters, right? It's not small, right? But the whole thing is used when we eat regular food. But when we have an elemental diet, it gets absorbed within the first few feet, maybe 1 meter, and the rest of it gets no exposure.

[09:00] to food. So the bacteria and archaea that are not native go away. Why? Because they are dependent on food to survive. But the native bacteria that are only survivable just by the sloughing of the bowel, they survive. So you get essentially a factory

[09:20] reset of your gut microbiome. So you get the lack of allergenicity, you get a lack of exposure of bacteria to food, so you get a gut microbiome. And also another thing that helps is that EDs, amino acids help

Defining Constipation and When to Seek Medical Attention

[09:40] with the building of epithelial cells. For example, glutamine is a very important amino acid that helps the epithelial cells, the lining of the bowel to heal. Otherwise, you get something called leaky gut. So the

[10:00] food goes through. But then when there is glutamine, it heals the lining of the bowel. And that's also another advantage of the elemental diet. So I said all this because interesting enough, we were giving people the elemental diet at exactly the same amount of

[10:20] calories that they need. We were not giving them less calories. But even though that happened, people did lose weight. And interesting enough, we didn't rely on BMI. I mean, you better than me know that BMI is not accurate, especially when you go to Asia or South Asia. It's pretty

[10:40] much useless. So what we did was that we did in-body testing. So in-body testing is essentially assessing the body fat percentage. Exactly. So we looked at the body fat percentage and also visceral fat content and also the muscle mass. So interesting enough, muscle mass didn't drop. Only

[11:00] So based on the study that you did, let's say a patient walks into your office, how do you translate that into a clinical approach? Right. So the next step that we're doing is that, okay, what exactly did we change that led to such dramatic performance?

[11:20] potential fat loss. So we will see whether it was via microbiome because we have stool, we have urine, we have saliva, we have blood from these patients to see what exactly happened. And eventually I think this opens another sort of potential door to help patients.

[11:40] Whether as a standalone sort of diet or even an adjunct. So to help patients to first of all get a reset on the gut and also lose some weight. Especially when we say weight, we want to make sure that what you lose is fat and visceral fat.

Pelvic Floor Dysfunction and Its Link to Constipation

[12:00] Exactly, and not the muscle mass because otherwise we're not necessarily achieving a positive result. So the most common cause that a patient walks into my office is constipation. Can you tell our viewers in terms of what is constipation, when

[12:20] Should the patient be worried about? It's actually fascinating that we don't have a perfect definition of constipation. So, you know, because people say that, okay, is it the frequency of the bowel movement? Or is it the consistency of the stool? Or is it just a sensation of, okay, I can't get this stool out of me, right? And probably it's in all of the

[12:40] above. If you look at the textbooks, they say that, well, if you have less than three bowel movements per week, then you're considered constipated. But there are people that come to me that regularly have one to two bowel movements a day. If they don't have a bowel movement every day, they feel constipated. So it's also an individualized approach.

[13:00] So it's interesting that we say the patient is constipated when they tell you they're constipated. So everybody is different. But essentially, if you want to put an exact definition on it, it is that when you are having a hard time evacuating the stool, essentially when you're having a bowel.

[13:20] Movement, you will have a sensation of incomplete evacuation and now on top of it, the bowel movements are infrequent and also the consistency is very hard. Consistency of the stool which is very hard on the Bristol Scale Chart may be in the first three or so and then even when the stool is in the rectum, it is very difficult to evacuate.

[13:40] It could be because of some neurological problems as well. Yeah, exactly. So the evacuation of something we call outlet issues. This is sometimes it's because the coordination between the anal sphincter and the abdominal muscles are gone. Very commonly in the setting of obstetric injuries, for example, very common.

[14:00] in women who have had multiple babies, or if the delivery was complicated with a tear, or some forceps were used to get the baby out. So that can affect the pelvic floor. So it's a very important point that you're mentioning to the audience, any women having complicated

[14:20] What you say is when a baby is big and is trying to come out, either the use of forceps as a device to get the baby out or you do an episiotomy where you do a small cut of the muscle to get the baby out or if it was like a long and complicated delivery. So that is why constipation is very common.

Yoga, Squatting, and Alternative Remedies for Gut Health

[14:40] Yeah, absolutely. So outlet obstruction is a very common issue. So we can diagnose that with many things. One option is to diagnose it with good old rectal examination. So essentially the doctor would ask you to

[15:00] squeeze and then push the finger out and they can see that the coordination is gone. There is a formal test, anorectal manometry, to see if the synergy defecation is there. So that is just for the audience in explaining, anorectal manometry is a small balloon that they insert into the rectum and then they measure the

[15:20] pressure of the sphincter muscle. Exactly. So it's essentially a catheter with a balloon at the end of it, right? And this catheter has some sensors on it and also the balloon measures the pressure. So the catheter sits and kind of straddles the anal sphincter and the balloon sits on

[15:40] So when you squeeze, the pressure is taken. When you push, the pressure is also taken by the rectal sensors and also the anal sphincter. And you can see whether there is this coordination. So the good news is that when we find this, the treatment is actually by feedback therapy.

[16:00] Which is when we ask our nurses or physiotherapists to teach you how to do this. Essentially, you're going to the gym for the pelvic floor. So basically you're training this neuromuscular circuit from the abdominal muscles.

[16:20] the pelvic floor to the internal sphincter and the external sphincter muscle. Exactly. When should a patient actually get tested? So generally when we hear that patient saying that hey listen I have a hard time evacuating right. So I'm sitting on the toilet for a long time and I can't

[16:40] get the stool out. Or I'm sitting there, only small palliative stool comes out and the rest of it, I know it's there, I can't get it out. I've spent one hour of podcasts on my phone already. Exactly. But when that happens, the most common thing that people go to is to take a

[17:00] Yeah, exactly. So that's another way. So you're right. So one way to treat this is to liquidify the stool and make it easier to get out. So despite that lack of coordination. So that works too. But so many times it's that sensitive.

[17:20] Sensation of incomplete evacuation won't go completely away if you use only laxatives. So that's one thing. So sense of incomplete evacuation is you have used the bathroom, but you still feel like going to the bathroom again, that sensation. Right. We're just actually in India for a

[17:40] conference and there was a fascinating research that was presented when I was in Hyderabad that they, I guess there is this type of specific Indian yoga that helps with the gut, right? And they use this to help with the constipation to a point that

[18:00] They could empty the patient for colonoscopy. Wow. Yeah, so that's actually fascinating to me. And again, that kind of reminded me how important coordination of abdominal muscles and pelvic floor are for us to evacuate to a point that they presented this fascinating research that they helped patients.

Methane-Producing Bacteria and Its Role in Bloating & Constipation

[18:20] prep for colonoscopy with yoga pre-colonoscopy. That was fascinating. And that just tells you how important. Of course, of course. You know, yoga itself is mind-body coordination. We call the post, post this in yoga, it's called asanas, okay? In India, it's called asanas. And the specific post that you're talking about is called

[18:40] malasana means stool. Asana means posture. If you assume this posture, the stool evacuation will be better. That's why it's called malasana. Okay, so that makes sense. I actually, you know, this is almost similar to the squatty-potty concept, but they just focus on the muscles. Now they focus on the

[19:00] brain-boring connection as well. Yeah, absolutely. I mean, glad that you brought the squatty potty. I don't know if your audience, how familiar they are. Yeah, yeah, yeah, please, please. I don't think they know. Essentially, a squatty potty is you put like a stool underneath your feet when you're sitting on a western type bathroom for your knees and your hips.

[19:20] to get flexed more, right? Kind of to sit on a Western toilet to resemble an Eastern toilet, right? When you essentially use squats, right? Because that's the perfect position of the stool to go out in an Eastern sort of toilet. And also that helps with my question.

[19:40] In my opinion, the Western toilet is the number one reason for the increasing rate of constipation. Do you agree? Well, I mean, that's definitely one of the reasons. It's because, first of all, it's too comfortable. Bathrooms are not made to be comfortable. You're supposed to get it done and get out. Right? So you're sitting there, especially in the modern age.

[20:00] We take our cell phones there, we just watch whatever or text and all that. So we're not supposed to sit on the toilet as much as we sit these days. Definitely that does not help with evacuation. And also the anorectal angle. Exactly. And anorectal angle.

[20:20] Definitely is a factor. And also when you're in a squatting position, your abdominal muscles can be engaged much better than when you're sitting on a Western toilet. So you can evacuate more efficiently and you relax the anal sphincter more efficiently. Definitely it helps. Let me ask you this. A patient comes in with constipation. We talked about all

[20:40] Okay, he said, give me a diet to cure this. Right. What is the first time I usually start with fiber? And why don't you tell us what do you do in your practice and the importance of fiber? Right. Definitely fiber is important. Although fiber is helpful in many places, I will talk about

[21:00] places that it may actually make things worse. So which is not surprising, right? Because that's what we used to do and we still do because fiber is very helpful. For example, Metamucil type sort of fiber that - psyllium husk. Yeah, psyllium husk that we use.

[21:20] That definitely helps with the majority of the patients and I definitely tell the patients to take a lot of water. Fiber without water is useless. And also I wanted to bust another myth. That water alone is not necessarily helpful because the patient. 95% of the water

[21:40] in our body is already absorbed in our small bowel. Only 5% reaches the colon. So even if you have 10 liters of water, 9.5 liters of it will get absorbed in the small bowel and you end up urinating more, peeing more rather than sort of like helping with the constipation. So water

Dietary Strategies for IBS, Bloating, and Gut Health

[22:00] is good in the setting of a good amount of fiber so it stays in the lumen. Otherwise, just water alone is not going to help you extra to help with the constipation. So that's one important point to understand. So the bacteria that produces a gas called methane. Yes. And if there's a test to

[22:20] identify whether you are producing methane. If that is positive, then which means that you have a lot of archaea that is producing methane. Exactly. It's just actually fascinating that methane is, we can't produce methane in our body. Actually, no mammal can produce methane. So all the methane that we breathe out and we found in our breath

[22:40] is simply produced by the methanogen or methane-producing archaea in our body. So the problem with that methane is that it slows down the gut. There was a very fascinating study that was done by Dr. Dykstra almost 20 years ago and they put methane gas in the intestine of dogs and

[23:00] And it showed that right away that methane causes spasm of the bowel. Because we have these very organized movements of our gut called peristalsis that pushes things forward. And in the setting of methane, these become aspastic. So it's not that there is no contraction.

[23:20] In fact, there is strong contraction, but it's not propagating. It doesn't push things forward. That's why these patients have cramps, but also things don't move. Patients with excessive amounts of methane get bloating, distension, constipation, and interestingly enough, when you give them, even though they have

[23:40] constipation, you give them extra fiber, all of a sudden they get super bloated, right? Because now this archaeal breakdown of the fiber produces more methane, right? So that's one specific type of constipation that gets worse with fiber. So you have to be careful. I see. That's not the case. But as you said, the good news

[24:00] is that this is easy. You can diagnose it with a breath test that measures the amount of methane in your breath. And if there is an excessive amount, there are different ways to treat it. For example, specific antibiotics; usually, we use poorly absorbable antibiotics like Neomycin, Rifaximin, and all that.

[24:20] that can decrease the amount of this bacteria and constipation improves. Also, the elemental diet that I mentioned for people who don't want to take antibiotics. But the elemental diet is not practically possible, correct? Yeah, I mean, it's becoming. It's becoming. That's the beauty of it, right? Because this is a trick that we would have taken out like

[24:40] Like in extreme cases now they're palatable now, which is actually fascinating to me. Yeah, elemental diet is again elemental diet is your diet broken into amino acids, carbohydrates, fatty acids without any degradation involved. And Dr. Dykstra was mentioning that it was very difficult to eat before but now it is making

[25:00] Exactly, because we just actually presented that out of an elemental diet, the rate of eradication of SIBO and EMO that we had, the overall rate was 73%. And the rate of eradication of SIBO with antibiotics maximum is 50%. So it's actually, I mean, if you want to compare numbers, there's no head-to-head study. But if you...

[25:20] If you look at it, it's actually a 7-bed, it's amazing how diet can revamp. So that brings to the point that diet is the medicine for everything. You are what you eat. But if you look at it, it's actually a 7-bed, it's amazing how diet can revamp. So that brings to the point that

Western vs. Eastern Toilets: Their Role in Constipation

[25:40] diet, patients should also consider increasing their fluid intake, particularly water, as hydration plays a crucial role in digestive health. Incorporating more fruits and vegetables can help, especially those high in water content, like cucumbers and oranges. Additionally, including healthy fats, such as avocados or olive oil, may aid in easing bowel movements. It's also beneficial to consider probiotics and fermented foods, which can promote a healthier gut microbiome and assist in digestion. Overall, a balanced approach focusing on hydration, fiber alternatives, healthy fats, and probiotics can significantly help improve constipation.

[26:00] So one thing that we talked about that I want not to forget is that definitely if you have an acute type of constipation that all of a sudden you refine and constipation occurs, make sure that you think about the medications that you've just started. I think that one thing before I've given you

[26:20] To the diet part is that so many times a patient comes in and is like, "Oh yeah, I'm constipated; I don't know what to do." I ask them, "Have you started something?" and they say no. I then ask if they are on any injectables or anything, and they say, "Well, yeah, I'm on Ozempic." I respond, "Oh, well that's it!" or it could be a migraine medication that was recently started. Exactly.

[26:40] Exactly. So these new and newer migraine medications that can help or like yeah for my joints I'm on like this painkiller. So that's one thing to make sure that that's not the case. Most of that data is on IBS diarrhea type and also IBS mixed type. They don't work as well.

[27:00] well in the IBS constipation time. So that's, again, the important thing that we need to understand that you need to, first of all, seek medical help. Number two, if you have access to a GI dietitian, get a GI dietitian sort of like help to help you, right?

[27:20] But again, the good news is that the majority of the patients, the fiber will help, and an extra amount of vegetables will help. One thing is when you have blood in stool, please seek attention. Exactly. It's a red flag. Some people just think about blood in stool as bright red blood in the stool.

[27:40] But when there is maroon stool and even tarry black stool, just like tar. Like a black, like a hair or tar. Exactly. That's actually the worst type that you need to seek sort of medical help. Or you're losing weight unintentionally. Exactly. So if you're losing weight unintentionally,

Colon Cancer and IBS: Understanding the Risks

[28:00] Because that's one other thing that I will say patients with IBS may lose weight, but if you ask them, their appetite is fine. It's just that they're avoiding some food saying that, well, I eat everything. I get bloated and I get a change of bowel habits so I don't eat. So that's why they're losing weight. So they're avoiding food. The main concern is the colon cancer. Yes.

[28:20] your experience you see a lot of patients with IBS. Are you seeing colon cancer in these patients as well? So that's interesting. So we just actually published a paper that showed that IBS patients have less colon cancer than non-IBS patients. Now exactly the reason is not known. Number one is might be

[28:40] The fact that IBS patients now seek medical help, they get colonoscopy, they get a sort of like a head of a polyp if it's existing. The other one actually goes back to gut microbiome, right? That shows that that change in gut microbiome may cause some problems, may help you in a way, right? So that's actually a very

[29:00] active field of research to see what is the role of gut microbiome and colon cancer specifically, which is fascinating and that might be the cause. So I have one good news for Dykstra patients, I guess, that the chance of colon cancer is less than general population.

[29:20] Based on the current evidence that they have. You know associated with constipation the biggest problem all my patients complain is about bloating. Whatever I eat I feel like I am nine months pregnant right after I eat and most of the times in my practice I see that they also have constipation associated as well. So abdominal bloating.

[29:40] Is it only constipation or is there something else that's going on? So it's multifactorial. So let's separate bloating and distension. Bloating is that sensation of fullness. Distension is when you visibly see that your belly is protruding, is coming up. You have to open up your belt and as you said,

[30:00] Like you feel like you're nine months pregnant. You see that it's getting bigger. Most commonly, it's happening after food. So we talked about that we have a lot of bacteria in our colon and much less in the small bowel, almost one million times bacteria in our small bowel. So whenever we eat.

[30:20] A set of waves happen in our gut. So if we eat for example a light meal to heavy meals, the food goes into the stomach, stomach enters a feeding stage. Feeding stage is that when the stomach starts to break down the food, like through the food and

Food Poisoning and Its Link to IBS Development

[30:40] grinding it, mixing it with acid and enzymes and all. This process takes about half an hour if it's, you have, it's in various light or all the way to four hours if you have eaten something fatty and a lot of protein in it, right? That mixture at the end has to be at

[31:00] least one millimeter in smaller size and it goes to the end of the stomach and slowly gets fed into the small bowel. Otherwise if it's not broken down, the pylorus which is the connection of the stomach to the small bowel doesn't allow, it closes off. The minute it's ready to be pushed into the small bowel,

[31:20] Then the fasting phase of the small bowel starts. The most common cause of this motility remains food poisoning or infectious gastroenteritis. Food poisoning. Yes. So when you get very common everywhere now, even in the US, CDC.

[31:40] is now reporting that 270 million cases of food poisoning occur every year, as that is happening everywhere in Asia and beyond. Because we travel more, we are becoming more adventurous in what we eat. Our travel habits have changed. We used to travel and go to resorts.

[32:00] whatever is in there now. When I traveled, my family was like, okay, let's go eat some street food, see what they eat. People eat here. You want to mingle with the culture. The culture of traveling has changed. So that also has increased the rate of food poisoning. So whenever you get infection

[32:20] cataractation, you have almost 11% chance of getting irritable bowel syndrome. 89% of the time it gets clear, but 11% of the time even though that bacteria is gone, you develop symptoms. So it's a very important point. I think 1 in 10 patients who has this food poisoning and

[32:40] or increases in developing IBS, irritable bowel syndrome. I remember the doctor was mentioning that whenever he goes to India or any other country, his wife is from India, I think so. And then he goes to India frequently. And he said that whenever I go there, I take this half a tablet of Rifaximin, an antibiotic before each and every street food so that

The Role of Artificial Sweeteners in Gut Health

[33:00] He doesn't want to be there one in 10. Practically, I'm not sure how possible it is. Yeah, I don't know if it's how plausible it is, but yes, but that's one way. But that's definitely one. And interesting enough, we know the exact pathway how this happens. I'm going to summarize what you just said. So you eat big.

[33:20] Balburi is one of the most popular street foods in India. I'm just giving you an example. So I'm eating balburi and then maybe the balburi was contaminated, we don't know. I get food poisoning which is bacteria called Campylobacter. Campylobacter is one of the food poisoning-causing bacteria and I have like three days of diarrhea.

[33:40] Right. So if it gets better after that, you know, I go light on the diet. But what we are saying is one in 10 times, the problem doesn't stop right there. Exactly. Three months, six months later, we start having bloating, constipation or diarrhea and abdominal pain. Right. And we are like, why? I didn't eat anything now.

[34:00] But what has happened is because of the infection three months ago, your body has developed antibodies to that particular bacteria. But your body thinks that because of molecular mimicry, this antibody looks like something that belongs to you and starts developing antibodies against your normal cells. That affects the nerves of patients.

[34:20] play of this monitor stem so that the waves are not being formed. Yeah, exactly. So a person with abdominal bloating, I feel full right after eating. What will you tell them to avoid in terms of food? Okay, so generally speaking, well, obviously, helping all these medications that we talk about, but in terms of food, what we do is that we

[34:40] start taking out the most obvious fermentable food out there. So remember, bacteria don't like proteins, bacteria don't like fat, they love carbohydrates, they like sugar. So I mean, the rule of thumb is

[35:00] less sugar the better. But in real life, how am I supposed to avoid that? So the big things that we suggest to avoid, number one, are artificial sugars. We tell them not to use artificial sugars because artificial sugars are made not to be absorbed by us, by bacteria. Love it.

[35:20] alcohols. So that's talking about sucralose, cortisol sweetness. Yeah, so. Aspartame. Yeah. Aspartame has actually good because that's a protein one. It's a dipeptide. I see. That breaks down. But sucralose, that's not a good idea. Okay. The other thing that I usually tell them to avoid are

Lactose Intolerance and Its Connection to SIBO

[35:40] essentially lactose. Because dairy associated lactose is very fermentable. Milk products. So I say lactose free milk or you can try a non sort of lactose milk. Oat milk. Oat milk is good. Almond milk. Almond milk.

[36:00] and all that. I know it might not be available everywhere, but yeah, I was just in India, had lassi. I don't know. I know milk is everywhere. I had my follow day there as Luda. Alright, yeah. So it was, it was, yeah. So there is especially at least my limited experience, Indian

[36:20] There were like a lot of milk in it. And that's why people actually develop bloating in the area mainly after milk products. How common is lactose intolerance with C-Bowl? Very common. So and remember it's not necessarily because you don't have that enzyme.

[36:40] Because the bacteria in the gut love lactose so much that they break it down before you digest it, and they produce gas. So that's one of the reasons that they have lactose intolerance, and they can't tolerate lactose, not because the enzyme is not there. My patient tells me that I was drinking milk at a young age, and I was completely okay.

[37:00] Now I'm 35. Now I drink milk. I'm having diarrhea. I'm allergic to milk. What will you say? So first of all, yes, that's the thing. So yes, adult loss of lactose tolerance, it's very common. It happens for many reasons. Number one, we talked about

[37:20] Specterium overgrowth. Now there is an excessive amount of bacteria that is breaking down the lactose. Number two is that when you pick up that food poisoning, right? So people probably have to Google this. Inside the lining of our small bowel, it's like villi. Fungal ache predictions.

[37:40] Exactly. These are finger-like projections. And the enzymes are all concentrated at the tip of the cells. Something we call brush border. Interesting enough, when you get an infection, the first, it's almost like it gets harvested. They just cut the tip of these cells.

Grazing vs. Fasting: How Eating Patterns Affect Digestion

[38:00] So you lose that brush border and the enzymes, for example, lactase that breaks down lactose, it decreases. So you do get acquired lactase deficiency after an infection, and that is one of the most common causes of lactose intolerance after an infection.

[38:20] infection too and all of a sudden an adult age. Yes, because when we're stressed, we do different things. We eat differently. We don't work out. We don't sleep well. For example, all those three things mess up the gut. If I don't sleep well, of course my gut is not going to function.

[38:40] Those housekeeper waves only happen during fasting. If I continuously graze throughout the day, those waves don't happen. You're suppressing them, right? So that's why people who graze throughout the day, they generally feel bloated because they're suppressing constantly the

[39:00] clearing waves. Thank you for supporting my fasting concept. No, the fasting concept is actually, okay, so now, Turkey, you know, to prove your fasting concept, because, you know, we have to go back to our evolution, right? So humans were built to wake up, have a bowel movement, right, and then go

[39:20] hunting, do our thing and come back, eat, and then do the same thing. So we were not built to snack like constantly throughout the day. Snack is something that is no less than, no more than 100 years old, right? So our gut was built to eat.

[39:40] And then having those during fasting phase, having those clearing ways to get rid of all the pathogens, all the excess amount of bacteria, and set the gut, make it healthy for the next round, right? So if you're doing grazing, which is anti-fasting, you're suppressing that sort of defense.

[40:00] mechanism and you're going to cause a lot of problems and you're going to mess up your gut microbiome and obviously that will lead to a lot of problems. So now one of the things that I tell my patients with IBS is definitely have eight hours of overnight not eating, no snacking in the middle of the night, between the

Cognitive Behavioral Therapy (CBT) for Managing Gut-Related Stress

[40:20] have five to six hours of like not eating. Don't snack in between. And yet tea is fine, coffee is fine. If drinking water is fine, you can do that. Mainly carbs. Yeah, exactly. Mainly carbs. Exactly. The most common thing when I'm stressed out is I eat, I overeat.

[40:40] What will you tell that patient? Yeah, so that's one thing. So that's that again, before talking about that, that tells you it's probably the constant eating that is triggering all the problems as opposed to stress itself causing all the problems, right? So that's one thing that you have to

[41:00] help the patient, obviously advising them not to do that. If you're at a tertiary center like us, I'm lucky to have a GI dietitian. I send them to a GI dietitian to help them to manage that. Also, in that situation, cognitive

[41:20] Behavioral therapy is very important. Please explain to us what is cognitive behavioral therapy because I want my audience to understand. Yeah, so cognitive behavioral therapy is essentially taking a step back, saying that, okay, this problem exists. Instead of denying it, instead of not coping well with it, let's accept it.

[41:40] let's come up with behavioral patterns to deal with it. So essentially how to deal with it. And that includes, for example, not eating constantly. So I'm like, oh my God, I'm stressed. Let's have another pint of ice cream. So that's not going to help. That teaches you how to deal with stress. So that's why cognitive behavioral therapy or

[42:00] CBT is not just for this. You can use it for any chronic disease to teach you how to cope and deal with it. So that will help you, number one, to deal with it better and also be more motivated to seek medical help to fix it. Also get rid of the Dykstra.

[42:20] behaviors that are worsening things during the stressful times. So that actually helps you significantly. So you mentioned about sleep. How sleep is connected to gut bacteria. Oh yeah. So it goes back actually to the housekeeper's ways. So when we

Final Thoughts & Advice on Maintaining a Healthy Gut

[42:40] sleep every two hours, 90 minutes to two hours, that housekeeper's waves are constantly happening. So essentially think about it that you're sleeping and the car wash and your gut is happening. So constantly cleaning and pushing everything into the colon. And in fact, actually pushing

[43:00] stool all the way to the rectum. So you wake up and then have a bowel movement and move on. So that's how we're designed to do. So you need a six to eight hour sleep to have at least three to four cycles of housekeeper's waves to get that

[43:20] system cleaned out and ready and primed for day after. That's why a good sleep matters, right? That's why a lot of shift workers, including us, have a hard time when they switch around because that process is affected. That's why, for example, when we're jetlagged,

[43:40] We get constipated sometimes. That's why we get bloated sometimes, right? Because that housekeeper's vase, that sleeping cycle is messed up, right? That's one of the reasons. So sleep is very important. There was a wonderful discussion. We talked about a lot. I learned a lot. I'm sure you would have learned a lot as well.

[44:00] Common GI diseases like constipation and IBS don't have to compromise the quality of life; there is help around. Please write down in the comment section how you feel about the episode, how common irritable bowel syndrome and GI symptoms are in you and your family members, and please also write down what all the other guests said.

[44:20] that you would want me to invite on our podcast because this is Gut Feeling with Dr. Pal, between me and you, let's make the world better.