The Poop Episode: What's Normal?

Prepare to transform your gut health knowledge as we navigate the sometimes "colorful" details and scientific facts all about bowel movements. That's right, we are talking all about poop with our special guest, renowned Mayo Clinic (in Jacksonville, Florida) gastroenterologist, Dr. Jami Kinnucan. She is an expert in inflammatory bowel disease, among many other extraordinary contributions in the field of gastroenterology and medicine.

With valuable insights from our guest, we cover it all in this episode. From discussing how the hues in your loo can reveal the state of your health to the details of the proper pooping position, we're taking a somewhat embarrassing topic to an informed next level. Dr. Kinnucan breaks down the facts on diet's impact on digestion, the role of stress on your pooping habits, and how to keep your "exit strategy" going strong!

Ever wondered if your poop's performance is up to par? In this episode, we decode the signals of digestive distress and share some humorous anecdotes that promise to change the way you view your daily deed. We tackle everything from cannabis to constipation, ensuring you're equipped with the know-how to interpret your body's messages. Plus, we float the idea (pun intended) of what it means when your stool defies gravity – it's a conversation too buoyant to miss!

Finally, we serve up a fiber-rich feast for thought, dishing out delectable advice for those tricky tummy troubles. Whether you're battling the bloat or seeking solace for your stool, we've got you covered with practical tips for a happier gut. Join our Gut Health Podcast Community as we digest the latest trends, debunk myths, and share a gutful of belly laughs along the way. Don't forget to subscribe and share – your gut will thank you!

Episode mentions:

Kate and Dr. Riehl's book
Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS

Crohn's and Colitis Foundation gut-friendly recipes (These recipes were reviewed by GI dietitians Kelly Issokson and Therezia Alchoufete. 
https://www.crohnscolitisfoundation.org/patientandcaregivers/gutfriendlyrecipes

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Transcript

Speaker 1: 0:00

This podcast has been sponsored by QOL Medical and Schar. Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you. Hello friends, and welcome to the Gut Health podcast, where we talk all things related to your gut and well-being. We are your hosts.

Speaker 2: 0:47

I'm Kate Scarlata, a GI dietitian, and I'm Dr Megan Riehl, and we have a really exciting podcast for you. Today we're going to be talking about all aspects of a topic that makes some people anxious, some people maybe giggle or squirm, some people uncomfortable, and then also just so many people are curious about this topic. So what is it? It's bowel movements, poop, bm's. You know we always have a thousand different questions. Probably, when you know, you might turn back and look what's going on back there, and now we are going to bring you an expert, as well as both of us, to talk about this.

Speaker 2: 1:24

So, before we get into our guests today, we just want to share a couple tips and tricks. When it comes to an effective exit strategy, we'll say and so the first one that comes to mind is the thing that happens when we first wake up, and sometimes within about 30 to 60 minutes of being upright, our body starts to give us cues, and it's really important that we listen to those cues and get yourself to the bathroom. And so you know, just like it's important to listen to our body regarding all kinds of different things in our world, using our intuition, your gut is telling you something and we definitely want to take care of it when we need to in the morning. We've got a lot of other tips and tricks when it comes to bathroom usage, and so, kate, maybe you could share a couple of your favorite tips and tricks that you find to be effective in this category. I love that.

Speaker 1: 2:19

So, first and foremost, I'm a huge fan of the squatty potty. This is a toileting stool where we raise our knees above our hips and what that does is open the rectal canal angle, which really allows for just a little bit more of a straight line shot into the porcelain throne. That's what we're going for. So engage your squatty potty is important part of the proper pooping position and, yeah, we talk about this in mind your gut, Dr Riehl and I. And so a proper pooping position is when your feet are slightly elevated, again, knees above your hips, and you lean forward about 30 to 35 degrees, and Dr Riehl always mentions that this is a really good time to do some deep cleansing breaths, which we'll get into, because that really does engage that pelvic floor and that's part of this whole effective proper pooping position that we encourage our patients that have maybe a little bit more challenges in the potty.

Speaker 2: 3:19

Yeah, but anybody can benefit from it, right? I mean, when we go into the bathroom and you think about a good cleansing poop, you want your spine to be straight, you want to be in that proper position Three P's we could even call it and so anyone, regardless of your bowel habits, can really benefit from this. And you mentioned the diaphragmatic breath. So, again, whether you're maybe suffering with some struggles having complete evacuation is what we like to look for and hope for or you're somebody on the urgent side. The diaphragmatic breathing is going to help to calm and soothe those digestive muscles. We're going to talk all kinds of tips and tricks, answers to your questions today, and we're going to be joined by our amazing guest. Really our privilege to introduce our guest, the one and only Dr Jami Kinnucan.

Speaker 2: 4:12

Dr Kanuken is known for her dynamic personality, her incredible patient care skills. She's a thoughtful mentor to many and really an advocate for women in the field of GI. She's also an inflammatory bowel disease specialist. She joined the Mayo Clinic in Florida in January of 2021 as a disease specialist and is a senior associate consultant in the division of gastroenterology and hepatology. Now, prior to this, she was with me as an assistant professor of medicine at Michigan Medicine, and so certainly we miss her up in the Mitten State.

Speaker 2: 4:50

But in addition to leaving Michigan and really bringing her leadership skills and really just she's such a wealth of information for the field of IBD and GI in particular. So you know, we're just so lucky to have her today, and not only is she going to share all of her information on poop, but she also does research in the area of cannabis and IBD. She's recently received a 2024 stardom award to look at virtual reality and how this impacts patients with pain. So you know we could pick her brain all day long, but today we're going to pick it about poop. So welcome, dr Kanukin, and we're going to start with a myth buster with you, because that's how we like to dive into things. So you know what are some common misconceptions about gut health or GI disorders that you think are important to dispel for our listeners today as we get started?

Dr. Kinnucan: 5:46

Well, thanks for having me, and I would love to meet this Dr Kinnucan. She sounds pretty great, but I am so excited to be a part of this. Very, very interesting and often not talked about, you know very much. People often don't feel comfortable talking about their poop, so we're going to talk about all things poop today, and I hope that people feel really confident when they look at their poop, that they know what might be contributing to. You know kind of what it looks like, but myth buster, all right, so I'm going to do maybe a more general one.

Dr. Kinnucan: 6:15

I think that people forget that they are what they eat, and so, kate and your field, you know, a lot of the things that we put into our bodies, you know, can have direct impact on the way we feel every day, and so I think when people come in not feeling well, one of the first questions that I talked to them about is what their day-to-day intake looks like, and oftentimes that's just a really easy place to start. But in the field of inflammatory bowel disease which probably many of your listeners don't have this, but maybe some of them do, you know many of our patients come in feeling better when they change certain things about their diet. They may be avoiding fibers, they may be avoiding lactose-containing foods, but that feeling better often makes you feel like, well, my disease is better. So my Crohn's disease is getting better because I'm feeling better, and that's typically not always the case. So, while foods can make us feel better, we don't have a lot of data that changing specific things in your diet will lead to ultimately change the amount of inflammation that you have from either ulcerative colitis or Crohn's disease, and there's been some larger studies that have helped looked at this.

Dr. Kinnucan: 7:14

Do I believe that food doesn't play a role in terms of the risk of inflammation, the risk of having a relapse of your inflammation? Absolutely, I think what we feed our bodies is so important, but I don't know that we've reached the understanding yet that diet alone is going to be able to treat inflammation. So one of the things that I want to myth-bust today, at least for those patients with Crohn's disease and ulcerative colitis, is you know, while you might feel better with certain food changes, don't be fooled that that's actually making your inflammation better, and so don't stop your medicines with the idea that maybe your dietary changes are going to be what's going to fix the inflammatory process that's happening, so hopefully that helps some of our listeners today kind of think about how they're interacting with their diet and their inflammatory bowel disease.

Speaker 1: 7:55

Excellent, excellent. I love that because I do think when people feel better sometimes, especially in inflammatory bowel disease, you know that they're on the right track and they may be from a symptom management. But you got to take a look and really listen to the doctors because medication is really paramount for many patients with that condition. So let's get some learn some deets on poop, let's get into some details. So is there a thing like the ideal poop? Is there the best shape, for instance, in lightness? What are we looking for? What's the golden, I don't know? Trophy poop, what is it? Oh gosh.

Dr. Kinnucan: 8:35

So I get so proud when my three and a half year old has that perfect poop. So let's kind of talk about what that looks like. I think that there's no perfection to poop but there certainly are poops that are more ideal in terms of what they look like. We on the medical side and if you've ever seen a gastroenterologist, you may have seen a Bristol stool scale and if you haven't, you can go and Google it and it will give you a range from one to seven of different types of poops and you can identify kind of what majority of your poops look like.

Dr. Kinnucan: 9:02

So the sort of ideal poop is a Bristol stool scale three or four. It should be easy to push out without excess fluid or liquid. So a type three and sorry to ruin if you're about to eat any sausage. Type three is like a sausage but with cracks on its surface. And then a type four is like a sausage or a snake, smooth but overall very soft, and this is really kind of that. Type four is really the middle ground, average stool. But we'll tolerate type three and four and there's variations, kind of even within a day or even within your week, and that's okay and that could very much be impacted maybe by what you fed yourself or if you were stressed or if you haven't slept well. So I think you have to expect variation, but the majority of the poops, when they're more in this ideal state, is that type three or four.

Speaker 1: 9:47

Love it. I always tell my patients they're not dogs, you know they're not eating the same thing. Live in the low stress lifestyle on the couch, you know. So the change in diet and stresses, so many factors, play a role in what's going to, you know, show up in the toilet bowl. But I like that. Three to four is the goal. Snake like it's a good target.

Speaker 2: 10:09

And on that scale. So one is going to be very like pebble, hard constipation. Seven is going to be loose liquid diarrhea, and so you know you might, you might start at a two and you know, get up to a five on in a given day, and that variation does not need to cause anxiety or worry, it's just a matter of you know. This is a tool, a strategy to start to give us some information in an objective way about the consistency of our poop, and I didn't touch on the color.

Dr. Kinnucan: 10:42

So that's sort of the consistency, but I'm looking forward to talking about the rainbow color of poop. But what does normal poop look like from a color standpoint? Again, this can actually vary. You know, any shade of really kind of a greenish to more brown shade can be within that sort of ideal poop color range. But it really is dependent on what you feeding your guts. That can really kind of change that variation. And so stool color can be very impacted by what you're eating but also the amount of bile, and bile is typically made by your liver. It helps you digest fats, and so little bile can lead to variations, and maybe we'll talk a little bit later about the rainbow colors of poop. And then a lot of bile can make it look more yellow, green, and so it really is dependent on a lot of those factors too.

Speaker 1: 11:24

Awesome. So let's get a little microscopic. What is poop made up? You mentioned bile, but what else is in poop?

Dr. Kinnucan: 11:33

Yeah, so we're gonna get a little bit interesting but maybe a gross question because probably many people don't think about, like what is actually in my poop. But let's get some scientific here. Poop actually typically contains about 75% water with some mixed in organic solids. So what are those organic solids? Well, bacteria is really the large component of that and that's why the microbiome and feeding a healthy microbiome is so important and can help you sort of move towards that more ideal poop In terms of formation and color.

Dr. Kinnucan: 12:03

And there's some variation. Anywhere from a quarter to 50% of your organic solids are this bacterial. Biomass. Nitrogen-based matter makes up another portion of those organic solids, and then 25% of your poops can be carbohydrates or undigested plant matter, and then there's anywhere from 2 to 15% and when we start to get on the higher range, that can actually represent a malabsorption issue when you have too much fat in your stool. So the last component is fat that's in your stool. So really, the things that you put into your body proteins, carbohydrates, fats are the things that are getting broken down, some of them getting absorbed and then much of them you're pooping out.

Speaker 1: 12:40

Love it. So we kind of touched upon color of poop and I know I've had a couple clients been freaked out after eating beats and have a bowel movement and see Bright red in their stool. And is this blood? Am I dying? You know, if you're not chewing well, those beats are gonna show up in the poop and they are bright red and it can be scary. What does the color of poop mean? Like, what are some of the? You know we touched upon some of them, but would green come from something in particular outside of bio? Could you elaborate a little on this?

Dr. Kinnucan: 13:15

Happy to walk through. I have a funny story about green poop. I think actually Dr Riehl was around for this green poop story. My kid ate a St. Patty's Day green frosting cupcake and the poop that came out about 12 hours later was the same color as the frosting. So I think what the story means to tell you is that a lot of things that you put into your body can actually Change the way that your poop looks from a color standpoint. So you mentioned green poop.

Dr. Kinnucan: 13:41

So think about it when you see a variation in your poop color is did I eat something? So green poop, leafy green vegetables, green food coloring, kind of think about that frosting standpoint, actually iron supplementation. So you can also think about what did I eat. But also, are there any medications that I'm on that can change my poop color? And so I think that can kind of guide you when you start to see variations in color Diarrhea and excessive bile.

Dr. Kinnucan: 14:05

So if you have too much bile or if things are moving too fast, even though you didn't maybe eat anything, you can get more of that green coloring to your stool. Now on the other spectrum is what happens if you have no bile in your stool, so light colored, clay colored stool. So again thinking through, did I eat something that might have turned things that color? Also medications, again anti-diarrheals can actually create that. So when you've taken a Imodium over the counter you can see more of those whiter stools. Maybe bile had more time to reabsorb and you're not seeing as much bile in the stool. If we think about some of the things within the GI tract that can maybe create that light colored or clay like white stool a Bile obstruction. So if you have a gallstone that is sitting in your bile duct and preventing bile from being excreted from your liver and Other things, things that are very rare, like a biliary cancer or a pancreas cancer. So bottom line is, if you see some light stools and they're happening more regularly, this is something you should seek medical attention for.

Dr. Kinnucan: 15:02

Now, yellow stools, greasy stools, can be seen if you're taking certain gluten containing foods. It can actually typically a sign of excess fat in the stool due to either malabsorption or higher intake. Malabsorptive disorders that can cause excess fat could be something like celiac disease. But there's quite a few things that can impact the small bowel. This typically, if you're having routine yellow, greasy floating stools, I would seek medical attention with primary care or gastroenterologist. The last two colors are actually what ones that you want to ensure that you're kind of heightened awareness on?

Dr. Kinnucan: 15:38

So do you see dark black stool? Two common medications that can cause that are iron supplements or anything that contains a bismuth, like a pepto-bismal or a Kale pectate which gosh, I haven't taken that since I was a kid. Also, if you think about things, you eat black licorice, it goes in black and it's gonna come out and it's gonna discolor your poop black. But if you see more of that sticky tarry molasses kind of consistency and you're seeing black stools, this can actually be a sign of something more significant happening, like bleeding in the upper GI tract, something like your esophagus, your stomach or the first part of your small bowel. So black tarry stools don't sit at home. This should prompt you to get more urgent evaluation.

Dr. Kinnucan: 16:17

And then the last one is red stools and I think you brought this up, kate, that red stools, you know, beats common thing that people take in. Red food coloring can do that as well. Cranberries of around Christmas time, thanksgiving, all that cranberry sauce, you ate tomato juice, you drink a lot of Bloody Mary's maybe, or red colored gelatin or drinks that can also create that red stool, but you never want to miss the fact that it might be blood. So if you're having consistent stools that are looking more red in color, this is something we can easily test for. So just get a test, make sure that there's not blood in the stool and if there is, that should prompt more urgent evaluation with the health care team. So important and I think you know for some people talking about their poop.

Speaker 1: 16:56

It's this embarrassing or I can't broach the subject with my doctor, or I'll just wait it out. We all talk about poop in our practice. I think all three of us could say that's probably a regular discussion. So just really important to take yourself to the health care center, talk to a nurse at the doctor's office. Whatever you need to do, this is not a topic to keep to yourself. We're all ears. We love talking about poop.

Speaker 2: 17:21

You're right, Kate, that you know we've probably all had multiple patients where they'll say, like I'm really embarrassed to talk about this, but I know you probably talk about this, you know, with other people and so I'm gonna just share with you and I'm like, yes, absolutely, and they'll make comments about we never talked about this in my family. I didn't know this wasn't normal or I didn't know what normal was. And part of our motivation for today's episode is to, you know, demystify some of this information and to also maybe encourage us to again normalize the book. Everybody Poops. My kids have a book called What is Poop and you know we talk about that. Going to the bathroom is something that you do, your friends do, your parents do, we all do it. We just want you to be sure that you're not going to be a part of this. We just want you to be healthy and if there are some alarm features regarding your bowel habits, then let's be mindful of that and make sure that we have the right help.

Dr. Kinnucan: 18:22

Does anyone feel that we should have gone to school to learn how to poop Right like what to eat, how, what position we should be in? I don't think anyone teaches their children. No one taught me. I think you figure it out by what helps you, but I feel like we all need to take a class in how to poop.

Speaker 2: 18:38

I love that idea poop class yeah, kindergarten, everybody like learns how to poop. Yeah, you know, we should bring that up with our elementary schools. I love it.

Speaker 1: 18:49

I love it. So should we delve into like just changes in poop consistency, constipation, diarrhea? Do you want to talk a little bit about Dr. Kinnucan?

Dr. Kinnucan: 18:58

Sure, we're talking about all things poop today, I think you know. Thinking about consistency, I want to kind of throw in a common question I hear is how often should I be having a bowel movement? Right, and I'm sure both of you have experienced that, because what's one person's normal it might not be another person's normal. So I think everyone has their own normal. But how do we define, you know, constipation? Well, constipation is defined as small amounts of dry, hard stool, typically fewer than three times per week. So if you're not having those Bristol stool scale three or four or at least three times a week, you might be more on the constipated side. And then diarrhea maybe is the other spectrum where you're having more liquid, loose, watery, urgent, frequent bowel movements, maybe during the day and maybe at night. So let's dive into, kind of, some of the things that we think about, at least on the healthcare side, and maybe this will help the listeners when, when they hear this, kind of understand like am I that person, am I having those those ideal three to four type Bristol stool scale, three to four type bowel movements, or am I on the harder side, pebble side, or am I on that more liquid side? And so the way that I think about constipation is really in two ways. Are there things that are slowing down a colon? That's where poop usually is formed. So it's formed by Dehydrating the chyme, which is the substance coming out of your small intestine. It empties into your colon and now the colon's job is to take as much liquid out as it needs to, to maintain this volume status, this hydration status for your body, to keep you kind of upright, not feeling like you're dehydrated. But then it's also a job is to move that now Hopefully perfect Lincoln Log from one place to the other, so not everyone's colons are as efficient in doing that, so you can have more delayed transit issues with constipation.

Dr. Kinnucan: 20:47

Actually, one of the things that I see in patients who've struggled for lifelong constipation and then I'll ask them about is tell me about what it's like to have a bowel movement. What do you do? Do you have a routine you talked about, kind of sitting on the porcelain, goddess you know? Are you maneuvering? Are you having to lean forward and back, or do you use a squatty potty? Do you have to use different maneuvers? Some women have to stick their fingers into their vagina to actually force a bowel movement to come out into the toilet and not a lot of people feel comfortable talking about that and they certainly aren't going to maybe offer that information up. So I'm encouraging you if you're sitting in front of a physician or a team member on the healthcare team talking about your bowel movements, be honest about the things that you need to do to have bowel movements, because that could be a sign that maybe your colon is working really well. It's getting poop from point a to b, but then it's getting stuck.

Dr. Kinnucan: 21:34

Because the pelvic floor is so incredibly complex. There are muscles and nerves and interactions that have to happen between your mind and your gut and if those aren't all working perfectly, you may not be able to push that perfectly can log out and different things can put you at risk for that. Women, we are notoriously at risk for pelvic floor issues or pelvic floor dysfunction. We have children and sometimes we breath and vaginally. Obesity can lead to pelvic floor dysfunction. If you are prone to heavy lifting or straining, that can cause and create challenges in your pelvic floor. So even if your colon is working great, your pelvic floor might not be.

Dr. Kinnucan: 22:10

And some common causes to things that really are around that delayed constipation includes medications. Medicines that we take can impact our colon motility. The most common medication that can do that is a narcotic which slows down everything basically in the entire gut and that can create delays and things to getting from your mouth all the way to your bottom or into the toilet. If you don't move or you don't exercise a lot. Moving your body is actually one of the ways that you can have those more ideal bowel movements on a more frequent basis. If you're chronically dehydrated, you are asking your colon to work so, so hard to be able to dehydrate that stool. It's creating those little pebbles or making that stool really, really hard, and, trust me, it is much harder and much more painful to pass hard stool. It is that nice soft stool.

Dr. Kinnucan: 22:56

Maybe you have underlying irritable bowel syndrome with a more constipation predominant, and that can create some challenges. And of course, who's traveled right? If you go on different vacations or if you're going to work meetings, you're probably eating a different diet, you're probably not drinking as much fluid and so travel alone, getting on a plane, can create some digestive issues and can make you not be on your regular schedule. And then actually people who have been chronically using laxatives can actually create some sort of dependence around that and there are very safe therapies that we use that can be used long term, but there are some therapies that actually are used for stimulants and then when your colon is not exposed to them it's not moving as fast as it needs to to create that. So that's really kind of how I talk to patients when they're coming in and they are kind of meeting those criteria for more constipation symptoms. But on the other spectrum of that scale, those patients are having more Bristol stool type 6, type 7, more of those liquid stools.

Dr. Kinnucan: 23:49

What are the common things that we think about are causing diarrhea. So you are what you eat and so there are different foods that can create more challenges with your gut. So dietary causes is usually number one. So I at least get a basic understanding and, Kate, I know you probably dive far more into detail than this but are you eating dairy predominant foods? Do you eat gluten? A lot of people are gluten sensitive but don't actually have a true allergy to gluten. Fructose containing foods can create a lot of gas, bloating and diarrhea and I think that getting this high level of intake and understanding about how your food intake is impacting your bowel movements is really important An actual diagnosis of celiac disease. There is a small portion of our patients in our country more common in patients who are in Ireland but we can see a gluten allergy and so that's celiac disease. But many people go gluten free that actually don't have an underlying diagnosis of Celiac disease and it may not actually be the gluten. We might be more worried about some of the wheat that might be in the foods that they're in. If you have too much bacteria in your gut, too much bacteria can create excessive production of gas and gas kind of moves everything out of the way and makes it harder for you to absorb the fluids that you need to, and so you can see more fluid in your stool and make it more diarrhea-like consistency.

Dr. Kinnucan: 25:06

Certainly, medications can put us at risk for diarrhea, and some of the more common therapies that's prescribed and actually now available over the counter that can create issues with diarrhea is using proton pump inhibitors. People also have been reading a lot about taking magnesium and that magnesium is going to change everything for them from a healthy point, but it actually has been giving them diarrhea. Caffeine, gum sweeteners different ingestions can actually create diarrhea. So I often ask patients if they're gum chewers. I feel like gum chewing used to be like an 80s thing. I don't feel like people chew that much gum anymore, if that you have too much bile.

Dr. Kinnucan: 25:38

So let's say you had a gallbladder removal several years ago and ever since then you've noticed you've had issues with looser stools. Well, bile is stored in your gallbladder. So if you no longer have this really important organ, while not everyone needs it you're going to probably be dumping more bile into your system and not absorbing as much of that bile and it's going to be getting into your stool and you might be seeing more of those greenish, yellow stools and more liquid inconsistency. And there are different medications that we can use for that. Of course, when people are having issues with both new diarrhea, sudden onset doesn't go away, or they've been having diarrhea for a while, we want to make sure we're not missing infection and so people can pick up different infections that we can measure with different testing.

Dr. Kinnucan: 26:17

There's different causes of colon related issues that can cause diarrhea. There's things that I treat Crohn's disease and ulcer of colitis and the most common symptom is often diarrhea. And then probably the more common thing and really the focus of that excellent book that I've had a chance to read Mind Your Gut is Irritable Bowel Syndrome, which can go on the spectrum of those harder stools and be more on the more liquid side, those diarrhea stools, and can sometimes be in the middle. So that's really how I kind of talk to patients if they come in with the understanding that they're feeling more constipated or they're having more liquid stools.

Speaker 2: 26:49

So you covered that whole spectrum right, like with constipation, are you drinking enough water, are you getting good sleep, have you been traveling? Is your environment different, is your stress different? All of that can impact things as well. As you hit on the diagnosis that we commonly hear in our patients with, which is disenergic defecation and about 50% of patients with constipation will have that diagnosis and in that instance we might then introduce working with a pelvic floor physical therapist and wherever you're at on the spectrum number one, it can feel uncomfortable to talk about this with a physician and you can kind of feel like, oh, you know, I've taken the mirror laxer, I've taken the amodium, I've tried to work on my diet, and you start to feel a little bit hopeless, like what are they going to offer me, especially if you've had a colonoscopy.

Speaker 2: 27:37

That was normal. But the reality is we can start to look at that holistic team and a pelvic floor physical therapist, a dietitian, a psychologist, and it kind of goes back to this idea that one provider doesn't have to do it all and you don't have to be alone in the management of the sensitive issue. So thank you for so holistically and comprehensively covering you know whether you are urgent or you are the slow turtle trying to make it to the finish line here.

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Speaker 2: 29:56

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Speaker 1: 30:14

That's right, Megan. We poured our heart and our brain into creating this book that provides so much valuable information, From the link between the gut, brain and food, the impact of stress, overload, and everyday tips to help to better manage life stressors. Easy to implement, symptom-specific interventions, nutrition remedies to calm your gut and maximize gut health, and all about IBS mimickers and so much more you won't want to miss this opportunity to live well with IBS.

Speaker 2: 30:48

The book is available in our show notes as well as at all major book retailers. So a couple other questions that I'm just curious about. We're at a conference. There's lots of people imbibing in alcohol and marijuana. We can smell it wafting from the streets of Las Vegas. Do those types of things, like if you have a big weekend out do those impact your stool? And I think also we talk about this with our college kids, right? How does alcohol and weed impact our stool?

Dr. Kinnucan: 31:20

Great question, I agree. So just for the record, we are not partaking in excess in either of those.

Speaker 4: 31:25

one of which is an illegal substance.

Dr. Kinnucan: 31:27

So excessive alcohol is a sugar, and so sugars can create some transient malabsorptive issues, and so you can see more liquid stools. And if any of your listeners have, either in college years or recently, have had a few too many drinks, you probably notice that your stools the next day might be more on the liquid side. You might actually be on the other spectrum. You actually might, because alcohol can dehydrate you. You might actually go onto the constipation side and those people may notice if they are taken in excess alcohol and may have more liquid stools. And then you bring up a really important topic that patients often talk about with me is the use of cannabis and how can they use cannabis to help them feel better. But let's also understand that cannabis can actually have a significant impact on the motility of your gut, and so the reason why patients who have baseline diarrhea maybe feel better when they're using cannabinoids and that can be cannabinoids, cbd or those that contain both THC with CBD.

Dr. Kinnucan: 32:19

There's direct impact. There's endocannabinoid receptors that are in your gut. Actually, the largest volume outside of the penile gland, which is in your brain, are in your gut, and so when you're using cannabinoid-like substances, especially daily or chronically, you may see a variation in your bowel patterns. So some patients who use chronic cannabis can actually notice that they're more nauseous, and they have chronic issues with nausea because they can get some delays in their gastric emptying. That also impacts their small intestine and their colon. So some patients may notice, if they were more on the diarrhea side and now they're using cannabis more regularly, that they actually can have more issues with either more normal bowel movements or they may be on the more constipated side. So again, everything you put into your body can impact your gut and it can impact the colors you see, the formation, you see how often you see it, and so I think it's just important that we're feeding our gut the healthy things to try to obtain those ideal poops so that we feel better.

Speaker 2: 33:13

Yeah Well, everything in moderation, right, and it's important. It's again. We get nervous to talk to our doctors about this. So now you don't have to ask whether you can, you know, but if it's impacting you, then it's certainly another factor to consider. Couple more questions. Just curious and I'm sure that my seven year old will love this question why does poop float sometimes and why does it sink sometimes?

Dr. Kinnucan: 33:40

Interesting.

Speaker 2: 33:42

Sinkers and floaters.

Dr. Kinnucan: 33:43

So it's really again based on what you eat. So your intake can change the way your poop looks, the way you know, obviously, the color and then sort of the consistency of it. So most toilet bowls have water in it, so anything that is less dense than water is going to float to the top, so things that might have less density than water. So your poop is more consistent with either you've eaten a lot of fiber, maybe you've had more fat, maybe you actually have an issue with absorbing fat, and if that's the case we need to evaluate that or maybe you have more gas. Maybe you ate some of those foods that are gas producing foods which are very well outlined in the book, those FODMAP foods, and that can create more of these floating stools, and certainly chronic floating stools yellow, greasy in color, with fat globules.

Dr. Kinnucan: 34:28

You can see. That really should initiate seeking care with a healthcare team member. Those that sink just means that the poop is denser than the water and that actually can be a sign of a healthy bowel movement. So a type three or four that sinks to the bottom goes right into that person, goddess whole. That's a great bowel movement, that's something to celebrate, and so that's actually something that is not very concerning. And again, floating stools here or there it's probably something to eat, but consistently having those floating stools and that's more of your regular, that may be something that you need to bring up to a healthcare team member.

Speaker 2: 35:00

Okay, so you've covered quite a few potential signs of a digestive issue that we should probably look a little closer at with a medical professional. What do you think are, like, the biggest red flags? Just if you could summarize it briefly so that people can kind of keep it in mind, what are those big red flags in terms of your poop that we wanna just be aware of?

Dr. Kinnucan: 35:22

If there's anything that comes out of this is people understand that you can have variations. It can vary within the day, it can vary day to day, but it's more of that if there is this consistent variation that we talked about in terms of some of the things that maybe you would seek care for. So certainly if you see blood, you're convinced it's blood, there's no question you need to at least seek care with your primary care provider or a gastroenterologist. They should warn an exam so common non concerning things that cause blood hemorrhoids, both internal and external. Internal we can't see, but we can feel them if we do an appropriate exam during your visit. And then external we can see them.

Dr. Kinnucan: 36:00

If you have a hard bowel movement that's difficult to pass, it can create a tear in the lining of your anal canal and that's called an anal fissure and that actually can bleed a lot more than you would think from a very small area. Let's just think about it like a cut there. So blood 100%. If you're having change in your bowel patterns. So whether that is, you're on the diarrhea side, you're on the constipation side and you may be having some discomfort and any weight loss. So weight loss with any changes in your bowel patterns is something that I would say immediate discussion with a healthcare team member. Weight loss is not something that we see.

Dr. Kinnucan: 36:35

That with variations in bowel patterns, it usually means that there's something that's happening. It might be that you're not eating enough and that could be. A simple answer is that you've been trying to control your bowel frequency with eating less and so when you eat less you're gonna lose weight. But we wanna make sure we're not missing anything. You know, mucus can actually be a normal sign of stool, but excessive mucus production, with or without blood, is usually a sign there might be inflammation somewhere.

Dr. Kinnucan: 36:59

So if you're seeing a lot of mucus in your stool on a regular basis, that would be something that I would seek care for. And then, of course, if you have any changes in your bowel patterns and you have a family history of a GI malignancy whether that's a colon malignancy or anywhere in the bowel bring that up with your healthcare team member. Allow them to do the next steps to really exclude some of those things that would be, if we waited, could be treatable, reversible, but if we wait too long, we ignore those important symptoms, could actually lead to catastrophic outcomes. So I think look at your poop and if your poop is changing, if you see blood, if you're losing weight, if you have symptoms that are persistent beyond just kind of here and there, bring it up with your healthcare team and they'll kind of work up what needs to happen next.

Speaker 2: 37:43

Okay now just a thought came to mind for our listeners 45 is the new 50 for colonoscopies. So unless you're really experiencing a lot of alarm symptoms and if you are having healthy, normal poops, then you should likely have your first colonoscopy around the age of 45, would you agree?

Dr. Kinnucan: 38:03

100%. If you have a family history of a colon cancer. If your family history was that they were 45 when they were diagnosed with colon cancer, you start 10 years earlier, so you don't wait until 45. But, yes, most people average risk no family history, otherwise feeling well, having those ideal poops, feeling good about their gut. Read your book, right, they read your book and they're feeling like their poops are on par. 45 is the new 50. And so make sure that you're getting that.

Dr. Kinnucan: 38:30

And then I'm still pushing towards colonoscopy over some of those home stool-based testing. What I tell patients is those home stool-based testing they're really good at detecting cancer. They're less good at detecting polyps, and polyps are those pre-cancerous areas, things that I can take out as a gastroenterologist and prevent you from having cancer. I usually like to see patients have one at age 45. And if they're overall low risk and they have one at 45 and they wanna opt in at 55 to maybe do some of those stool-based testing or maybe in the next 10 years we get better tests that can predict polyps more than they're predicting cancers, then I'm okay with it.

Dr. Kinnucan: 39:09

But I really struggle, especially with more in the news. You've seen, what we're seeing in the GI community is early onset colon cancer, people that are getting cancers earlier and earlier, and so, personally, when I turn 45, not there yet I'll be getting my colonoscopy and then kind of going from there. So that's I really encourage. But screening, no matter which way you do it, as long as you get screened. So if you can't take off work, if that's not something that's in your cards you don't wanna get a colonoscopy, for whatever reason that might be then I want you to get screened in some way. So poop it in a box. If you haven't seen the Saturday Night Live video hysterical, but poop in a box, send it off. At least make sure that there's no concerning findings there.

Speaker 2: 39:46

Wonderful. So last thing, that we've picked your brain a lot and we'll probably all go have a different experience in the bathroom the next time we go today. Thanks to you and all of your information, we'll either be really reassured or maybe we'll make a phone call. We'll see. But I think I know the answer pretty well to this, but I'd love to hear the gastroenterologist's perspective. So how does stress impact bowel movements?

Dr. Kinnucan: 40:12

gosh, I don't know that there's any listeners on here that have never experienced stress, right?

Dr. Kinnucan: 40:16

Stress impacts us in different ways, but, absolutely right, how many people do you know that say that they have a nervous belly right when they're asked to either speak in public or they're in a stressful situation that they're like I need to have access to a bathroom and they really don't have any other issues outside of those moments? But in those moments, that connection between your central nervous system what's revving up in that stressful moment and your enteric nervous system, the nervous system around your gut, is so incredibly strong and in some people it's stronger than others, and so some people can be more impacted in those stressful situations and that the way they feel stress is actually in their belly. So you know this. I don't need to tell you this, Dr. Riehl. That mind-gut connection is complex and impacts people in different ways. But, yes, stress can impact your bowel, but it doesn't always have to impact your bowel. Personally, when I'm stressed, it definitely impacts my gut and I definitely know that I'm experiencing some stress in my life.

Speaker 1: 41:10

Love it. Definitely. The gut and brain are highly linked and so we have to, you know, think about diet, follow up with the doctor if your poop looks a little funky and it's changing and you're concerned, and keeping the stress in check, or pay attention when you notice that stress is definitely impacting you. So I wanted to do just a quick high level, real quick, a couple tips for diarrhea from a nutritional standpoint or supplement standpoint and I know Dr Kinnucan really talked about a lot of these so I'll keep it real high level. But if you're prone to diarrhea, caffeine can definitely stimulate motility. So overdoing caffeine coffee, tea, chocolate can probably be a culprit to some of the diarrhea. Maybe dial it back a little bit.

Speaker 1: 41:55

We talked about alcohol, keeping it moderate. Excessive alcohol can affect motility, brings water into the gut, can lead to excess diarrhea and have really negative effects on the gut microbiome if you're overdoing it. Another important sort of lifestyle factor is chewing your foods. Digestion starts in your mouth. So if you're seeing clumps of lettuce in your stool, you're probably not chewing very well. So consistently seeing food in your stool is something also to pay attention to, especially if it's recognizable chew a little bit better.

Speaker 2: 42:27

And that could be a sign that maybe slow down a little bit. Are you rushing through your meals? Are you eating on the go, are you? You know I'm busy, mom right, we sometimes are standing up eating our dinner while we're putting the plated food that looks beautiful down for our toddlers. But you know, if you're seeing that food and maybe you're also acknowledging the role of stress in your life, use your poop as your flag to check in and kind of recognize maybe I need to slow down, maybe I need to prioritize myself a little bit, and we all deserve to chew our food well enough to digest it right.

Speaker 1: 43:01

Amen, absolutely. Another little trick for diarrhea is cilium husk. Because it's a gel forming fiber, it can really sop up those extra fluids in the colon and make this stool a little bit more formed. Interestingly, it also works for constipation because it adds some bulking and softening to stool too. So cilium husk is one of those fibers that not everyone tolerates but is one that I often recommend. And of course pelvic floor physical therapy we talked about that can be helpful for both constipation and diarrhea predominant, especially with fecal incontinence and diarrhea can be helpful. And then in our patients that you know have that disnergic defecation that Dr. Riehl mentioned. Any thoughts on constipation in lifestyle, Megan or Dr Kinnucan?

Dr. Kinnucan: 43:49

No, I was actually going to ask you a question. Can I ask questions?

Speaker 1: 43:52

as the guest.

Speaker 2: 43:53

You're allowed.

Dr. Kinnucan: 43:54

Can you explain to me and our viewers? A lot of patients try fiber, but not all fibers are created equal my understanding. Can you explain soluble versus insoluble fiber for both me as the simple gastroenterologist as well as for our patients, because I think patients think fibers all the same. I'll tell you my story, as I was eating a lot of those fiber one bars and gosh, I had never felt more bloated in my life than after eating those fiber one bars. But I finally figured it out. I was like, why do I feel so bloated? And it was because I was eating those fiber one bars. So what was I doing, Kate, right.

Speaker 1: 44:28

So fiber one. They use a lot of the chicory root or inulin as one of their top ingredients and this is a highly fermentable fiber, so causes a lot of gas. Even if you don't have a sensitive gut, if you're downing a couple fiber one bars, you're going to know that you are downing a couple fiber one bars because it's a highly fermentable fiber. Your microbes are eating that fiber like fast food and they are creating copious amounts of gas. So to your point, soluble and insoluble fibers just a generic, you know, kind of describing can the fiber mix in water or can it not, or does it not mix in water? And in general, soluble fibers tend to be the food for our gut microbes and in general tend to be better tolerated fibers.

Speaker 1: 45:10

An irritable bowel syndrome, for instance, wheat bran, which is an insoluble fiber, can really cause diarrhea, mucus secretion in the intestine. So when we're thinking about fiber, just high level solubility matters. Is it going to mix? Is it a gel forming fiber? That's also really important. We love gel forming fibers because they sop up the fluid, can help with diarrhea and then they also soften stool. So that is psyllium husk. Another example that's in that category would be beta-glucan, which is in oats.

Dr. Kinnucan: 45:42

What about benefiber?

Speaker 1: 45:44

Yeah, benefiber is wheat dextrin and actually that can have a constipating effect. So even though it's often prescribed for individuals with constipation, it really doesn't benefit them. So fiber choice matters and if someone's highly gaseous, we don't want to give them a fiber. That's going to be highly fermentable and we want to make sure that the fiber is also intact in the colon if we want it to work. In the colon it's completely digested and broken down by our microbes. Because it's highly fermentable, it's not going to really probably help with softening stool or sopping up fluids. So, yeah, did that answer your question?

Dr. Kinnucan: 46:22

It did. I mean, I feel fiber-educated, because I think that patients come in saying I eat plenty of fiber, Dr. Kinnucan, I don't need more fiber. And so now I feel like I have some very smart words to use when I'm talking to them that you probably aren't actually eating enough fiber, or you're actually eating probably the wrong fiber, and so let's kind of help you eat the right fiber, so I love those suggestions, thank you.

Speaker 1: 46:44

Yes, and just to quick, since we're on the fiber train right now. So most Americans have about 15 to 18 grams of fiber per day and we're really trying to go for about 25 for women and about close to 35 for men. So most of us are under consuming fiber. But different fiber tolerances and different foods will work individually because we have our own individual fingerprint of our gut, microbiome and just genetics and a number of other factors that play a role here. So fiber should be tailored to your body and what works for that. So I know we're, you know, don't want to run too, too late, but just a couple constipation tips. I want to mention the two. Green kiwi fruits are my favorite recommendation. It's a well tolerated fruit. You can add it to smoothies, but they have special fiber that helps manage constipation by bringing water into the gut and stimulating the motility receptors in the gut and can be a really good nutritional, holistic approach to managing constipation.

Speaker 2: 47:44

Well, thanks, for those tips I always love. Like the recap right. We've covered so much. You could go back and listen to this episode over and, over and over, and I've really let all of this information resonate so that high level is really helpful.

Speaker 1: 47:56

Absolutely so I thought maybe we should do just like a quick status update. I know you and Dr Kinnucan are hanging together right now in Vegas. Did you want to share a little bit about what's going on there?

Speaker 2: 48:08

Yeah, so we're both here for the Crohn's and Colitis Foundation Congress, which is really bringing together experts in the field in the world of inflammatory bowel disease. So Dr Kinnucan is heavily involved in leadership. I serve on some committees as well and also, you know, really just learning about the innovative things that are happening for this patient population. And so, as we said, we're in Vegas and we're paling around at the different offerings of this exciting conference and always fun to see my friend again.

Speaker 1: 48:43

I love that. You know one thing I really note with the Crohn's and Colitis Foundation they are so good about bringing in the patient voice to their sessions. I just it's so important to hear from the people that are living with these conditions and their perspectives and just haven't seen it done as well as the Crohn's and Colitis Foundation. It's just. It's pretty amazing what they do, not only the patient voice.

Speaker 2: 49:07

yeah, but the multidisciplinary perspective. So at this conference there are social workers, there are GI psychologists, there are dietitians, there are rectal surgeons, there are gastroenterologists, so really getting the perspective and insight of how do we help patients from a holistic, multidisciplinary perspective.

Dr. Kinnucan: 49:27

Yeah, and I would. I was actually going to say is that you know the same thing that Megan's saying is that it's not just about physicians, it's, you know, about the whole team. And one of the things you know, speaking about food and diet and then I think, kate, you've probably been involved with this is the the gut healthy recipes that they have on the Crohn's and Colitis Foundation and, and those are actually recipes that don't necessarily even need to be specific to patients with Crohn's disease and ulcerative colitis. I've used some of the recipes myself and they're excellent. They are kind of healthy, nourishing, feeding a healthy microbiome, really kind of focused, but also geared towards ulcerative colitis and Crohn's patients. You know more in that Mediterranean focus type diet, so that's also another resource that the foundation has, so very patient centric, I agree, and about the team and and how do we better care for patients as a team? So Absolutely.

Speaker 1: 50:11

I can't say that I've created those recipes. I have to give credit to Kelly Isaacson and Laura Manning, I think have been really key on developing that. But in addition to the gut friendly recipes, just so many great resources, not only for patients but also clinicians. I often go there to just check out, you know latest on iron and different topics and EMEA and what the recommendations are. So that's awesome.

Speaker 2: 50:35

We'll link some of these resources in our show notes so that we'll give all of our listeners easy access to some of the resources available online. And let's talk about my nutrition challenge, right? So last episode, Kate gave me the challenge of expanding my vegetable intake and I will have to say, when I stepped back and kind of looked at what I was consuming, we actually do eat a pretty wide variety of vegetables in our house. It was just a matter of was I ingesting them as regularly as I was giving them to my kids? So God love the Costco for making it a little easier. I made sure in my last trip that I got like the extra large organic frozen veggie mix. That really helped me bump up my color variation. But in the last month we've been talking more about it as a family, like what colors are on our plate.

Speaker 2: 51:31

I'll admit, I am the bagel grabber in the morning. So just having you know, kate, in the back of my mind as I was getting my bagel was what could I have with it? And even this morning, you know, the cinnamon roll looked really, really good. I'm not saying that I'm not going to indulge later, but I did grab the yogurt with the gorilla and the different colored berries. So I think, just having somebody with accountability and encouragement, I over the last month I've made some really healthy choices and certainly been using like the smoothies and salads to get that variety. So thank you, kate, for that challenge. My microbiome thanks you. My kids' microbiome is. You know, the kids were doing pretty good anyway, but a busy mom was prioritizing herself a little bit.

Dr. Kinnucan: 52:20

I have an important question in this All of these changes you've made, have you seen a difference in what the porcelain goddess sees? She's happy honey.

Speaker 2: 52:28

She's happy, I love it.

Dr. Kinnucan: 52:33

Kate making poop happy left and right.

Speaker 1: 52:35

Exactly, that is exactly. I am very well known as like the poop person in all of my friend circles, like everyone's always, you know, like oh, she's always talking about poop. My father-in-law will say that as well. Oh, she talks about poop, she's an expert in poop. Well, I have some very exciting news. What I want to first talk about my challenge.

Speaker 1: 52:56

So I was feeling a little anxious. We were planning on getting a puppy. We have lots of just work, I don't know a book being published, a new podcast, a few extra things on my plate, and so Dr Riehl really gave me a recommendation to get my butt outside and do some more outside walking. I definitely enjoy being in nature and I really incorporated nature walks not just walking, but nature walks and it is so grounding for me. And so I got three nature walks in this week and I heard your little voice in the back of my head saying just get your nature walks. Self-care is important for you. So that really added a nice balance to a very busy work week. So that was my positive. In one other little bit of news, I learned yesterday that the mama puppy, the chocolate lab mom, just had her babies yesterday. So there are eight cute chocolate labs born, and so my little girl pup is waiting for us. So we'll be picking up our puppy in about eight weeks.

Speaker 2: 54:01

So it'll be my home. Congratulations, do you?

Dr. Kinnucan: 54:05

have a name picked out.

Speaker 1: 54:07

We do have a name picked out. Her name is going to be Mabel and it's after a little lobster shack in Kennybunkport. Because we summer in Maine and when we pass we walk by Mabel's all the time and I'm like you know that's kind of a cute name and it ties to one of our favorite happy places. So Mabel June, we have a middle name, Scarlata. Love it.

Dr. Kinnucan: 54:33

She needs to make an appearance on this podcast for sure.

Speaker 1: 54:36

You know, she will, you know she will All right.

Speaker 2: 54:41

So I think because of you know just the pace of life, we keep our challenges going. We're going to go one more month with these challenges getting outside, eating that wide variety. That's going to give us time to implement more of habit and ritual with both of our challenges. So again, all of our listeners, we hope that you're joining us in this challenge and you can leave comments for us on social about how that's going. Send us your pictures, engage with us. We would love that. And you know, hey, it's a safe space. So if you want to let us know what's going on in the toilet, we're fine with that too. Let us know.

Speaker 1: 55:15

Thumbs up, thumbs down, exactly Couple poop emojis Happy poop or unhappy poop.

Dr. Kinnucan: 55:23

Yeah, exactly.

Speaker 2: 55:24

We hope. Happy poops, happy poops, yes, okay, so we all poop, and if we don't talk about it, sometimes people suffer for decades, and so we just want you to normalize this. Talk with your doctors if you need to. And, Dr. Kinnucan, thank you so much for all of the wealth of information that you've shared with us, and we hope that everyone learned a lot today, because don't forget proper pooping position, couple nice deep breaths and your next number two could be number one baby.

Speaker 1: 55:59

So, Megan, what's up for our next episode?

Speaker 2: 56:03

Next up it is IBS. Is it Mimikers? We're going to talk to Dr Bill Chey, the chief of gastroenterology at Michigan Medicine. He happens to be my boss, a mentor, a friend to both of us and he also wrote the forward of that book that I did not pay Dr Kinnucan throughout our episode today. I did not, she plugged this all on her own, but Dr Chey wrote the foreword for our book Mind Your Gut. So this is going to be another really fascinating episode where we get to talk to a really key opinion leader in this field. So you will not want to miss it. To do that, to make sure that you don't miss, make sure that you subscribe and follow and, like The Gut Health Podcast, leave us a comment in addition to subscribing, and we can't wait to connect with you next time.

Speaker 1: 56:48

Friends, Absolutely have a great month ahead and we'll see you soon. Thanks for having me, guys. Thanks for coming.

Speaker 2: 56:58

Thank you for joining us as we grow this Gut Health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.