What's the deal with poop?

24:32So frequency is actually not a very good discriminator about whether you are sick or you're healthy. So like if you're pooping 15 times a day, you probably are spending all of your time in the bathroom. That's like a signal of a problem. If you're pooping less than three times a week, that is also likely a signal of constipation, but there's a pretty wide range and you could be having issues with your digestive system, even within that range.

24:58Emily Oster:Right. Most people, even with irritable bowel syndrome or inflammatory bowel disease, significant GI problems still fall within that range. So it's not actually that helpful. There's as much variation between people. What I think people don't talk about... Well, let's talk about consistency because we have to talk about the Bristol stool. Bristol stool scale. Bristol stool scale. The good people at Bristol have created a qualitative scale to judge what your stool looks like. And it ranges from type one, which is described as separate hard lumps like little pebbles, I think like rabbit poop or something like that, all the way to type seven, which is watery with no solid pieces.

25:48Emily Oster:Those are both abnormal. The sort of standard, I don't know, recommended healthy-ish Bristol school chart are types three and four. Type three is described as sausage shaped with cracks on the surface and type four is thinner and more snake-like plus smooth and soft. So that's what we're looking for consistency wise. And most of this is driven by water absorption, which happens along the colon. Your colon reabsorbs a lot of the water from your stool. And it does that based on the transit time of passage. So like the longer stool sits in there, the more water gets sucked up and the drier and harder and lumpier it gets.

26:33Emily Oster:And we don't talk about transit time. But transit time is interesting because it varies quite a lot. Something, you know, normal transit times are something like 10 to 75 hours. And that's actually a huge range. And that's mouth to toilet transit time. Mouth to toilet transit time. And you can test mouth to toilet transit time by – there's actually two ways. So a free way to do this is to eat corn. So most people cannot digest like a lot of corn kernels. So if you eat a corn on the cob and then you wait to see when you see the corn kernels in your poop, that's a good metric. You can also dye your poop blue.

27:15So there's different commercial and other frosting related ways to do this. You can do this accidentally. You can do this accidentally. And that's fun. That's like a fun activity.

27:26Emily Oster:Can we play a clip? Because this is getting like the blue poop challenge is an Instagram thing. Let me play that for you. Have you done the blue poo test? The purpose of this test is to see how fast the food that you eat goes through you. So you make blue colored muffins, you eat two of them for breakfast, and then you wait to see how long it takes for your poo to turn blue. This will tell you your transit time. Most people should be aiming for between 14 to 50-ish hours of transit time. If it takes you longer to see blue poo in the toilet, it might be a sign that you're constipated or that your digestion needs some work.

28:02A big contributor to pelvic floor dysfunction is constipation, and optimizing the transit time is one part of improving your gut health and eliminating constipation.

28:12Emily Oster:So this is something you can do in the comforts of your own home. What kind of food coloring to add? I've seen online royal blue food coloring, right? You want to dye like a muffin or something like that. And the normal transit time, as you said, it's between 10 to 75 hours. So 10 would be sort of the short end and 75 would be the long end of time between eating a blue muffin and seeing some blue or maybe greenish or some abnormal color coming out the other end. Now, having said that, like transiting your poop very quickly is not like a life goal, right? This idea that like we are trying to like poop max and get our optimal frequency and like have a laxative so the poop gets out fast.

29:04So like, that's not a thing you need to do. So very long transit times can be associated with constipation because the water gets pulled out and pulled out. And so that's like something to be aware of. But you shouldn't be trying to take the blue poop challenge and then like optimize so the poop comes out as fast as possible. That's not, that's not just not healthy.

29:26Emily Oster:No, I mean, too fast would lead to malabsorption. And you want to digest your food. That's everything, right? It's what you're using it for. If you read online, people say, oh, transit time within this normal 10 to 75 hour range has not been associated with any particularly bad outcomes. So it's nothing you need to worry about much. But when we get into the microbiology of poop, the different types of bacteria are in there, what we find is actually a lot of that variation is driven by transit time. So I'm going to table that for a minute as we talk about the, so that when we talk about the fecal microbiome, we can remember that transit time is a thing.

30:10Emily Oster:And maybe knowing your transit time, maybe, yeah, it doesn't give you any life goal in terms of making it shorter or longer or whatever, but it's nevertheless interesting information from sort of a scientific and physiologic standpoint. And it's fun. Okay. Before we get into all of that, I think it's worth saying, what are the things that would make you worry about your poop? Like what are the things to be concerned about if it's not transit times or frequency? So one is if there is blood, blood in the stool always deserves a call to your doctor. I will say that, fun fact, about 40 % of serious runners have blood in their stool sometimes.

30:51It's very, very common after like a hard effort after a marathon. Yeah. Because when you're working really hard for a long period of time, your body basically pulls like everything it can out of the gut, like your digestion just totally flakes apart. Okay. And then you have bloody diarrhea after, uh, and it is bright red blood, like just looks like what you'd be very worried about. Okay.

31:17Emily Oster:I, can we do an episode on like humans shouldn't run marathons. Hot take. The first guy who did it died. Died. It's true. But he wasn't fueling adequately. So I think that's something to think about. What with the new carb options? Anyway, different episode. But I will say, even if you are a serious runner, if you are pooping blood, you should tell your doctor about that and you can decide what to do. Okay. Your poop shouldn't be black unless you are taking a lot of iron, which will turn it black, and it shouldn't be pale. That can be a sign of a problem with your gallbladder. Is that right? Yeah.

31:54Emily Oster:I mean, pale poop is pretty scary. Gallbladder obstruction, which could hopefully be a gallstone in the common bile duct, but more ominously could be a sign of cancer that's obstructed in the common bile duct, which we don't love. So definitely get that checked out. The other thing is just weight loss and unexplained changes in pooping. Those are potential symptoms of a serious issue. And people generally should not routinely poop at night. So in the middle of the night pooping, sometimes it happens, but it's not a typical way your body would digest. And if that's a regular thing, that's also worth a call.

32:30Yeah.

32:31Emily Oster:We talked about this in a prior episode, but I think that pooping is this amazing example of the brain-gut axis because your social environment cues you to poop. We've talked about how for a lot of people, it's like they don't feel like they've got to go and then they get home where it's like, ooh, my nice toilet and everything. And then it's like, oh, now I have to go, right? That's your brain telling your gut, let's go. Now's the time. Coffee does this too. So caffeine obviously can stimulate your colon, but actually decaffeinated coffee prompts people to poop as well. And that's probably just a learned behavior and your brain talks to your gut, which is why sleeping, you generally, like your brain knows that it's not, you shouldn't be pooping in your sleep.

33:17Emily Oster:So if you are, talk to a doctor. Okay. So that is what your poop tells you on a basic, like what you can observe in the toilet. I think the two other big pooping questions for me are what can change your poop. So if you do find yourself in a bad part of the Bristol stool scale, like in the rabbit poop era of your Bristol stool. What can you do to fix it? And then I want to talk about the microbiome because it's very hot right now and people are totally into it and they want to know about it. So we're going to do both of those things. But before that, let's take a quick break. We all miss the 90s, the music, the shows, the outfits, and without a doubt, the snacks.

33:58Simple Mills is bringing back the golden age of snacking. They taste delicious, like the snacks you grew up with, only they're made with real ingredients like watermelon seed flour, almonds, cashews, flax seed, and organic coconut sugar. Fancy.

34:12Emily Oster:You'll love the throwback taste of cheddar pop-ums, the nostalgic flavor of mini crunchy chocolate chip cookies, and the familiar crunch of honey cinnamon sweet thins. Available in snack packs that are easy to toss into lunchboxes, backpacks, or your own bag. Simple Mills snack packs are simply the coolest. Simple Mills, throwback taste. Grown-up ingredients. I'm Martha Stewart from the Martha Stewart Podcast. In this special episode brought to you by McCormick Signature Seasonings, I got to chat with Reddit founder Alexis Ohanian about his new venture, Retrieve Air. We also get to talk about his family life and playing the weekend chef.

34:53Emily Oster:I'm a simple man. I use honey from the farm and I got my crepe. That's it. The girls like their Nutella. That's my breakfast ritual. I'm usually phoning in lunch a little bit because I'm really planning on a delightful dinner. The girls really like steak. I spoil them. So even if I'm doing kebabs, I'm using ribeye, I'm doing it right. Okay, well, please. Listen to the full episode of the Martha Stewart Podcast wherever you get your podcasts. I thought I looked so cute. I pieced together a cute outfit. And this girl comes up to me, just sits next to me, telling me, oh, hey, girl, I see your skin.

35:30I know what you're suffering with. I just remember feeling so just, like, distraught and, like, robbed of my time. When I finally freed myself of that conversation, the lights were coming on and the party was over. It felt like I had a sticker on my forehead that said, she has eczema.

35:49Emily Oster:We've all been there, wanting to go out, feeling cute, forgetting about all your problems, and just existing in the present with joy. But when you live with a visible skin condition, that can be a lot harder than it needs to be. This is Skin Queries. Listen on the iHeartRadio app, Apple Podcasts, or wherever you get the stories that make you feel understood.

36:16Okay, we're back. and I want to talk about fiber maxing. Perry, are you fiber maxing?

36:23Emily Oster:Oh, so no. We already did protein maxing. I'm too focused on protein to focus on fiber. Sorry, you got to do both. You got to do both. And none of them are in this like cheese powder that you eat all the time. So you're in trouble. I had my, do I have it here? No, I had my protein drink, my like Oikos 30 grams of protein, whey protein milkshake, which has no fiber. I'm actually concerned about our lack of fiber given our protein maxing stuff. Emily, I have no evidence that this is true, but I'm going to assert it without evidence. Only here on the Wellness Actually podcast will you hear the hosts admit that they're asserting something completely without evidence.

37:03Emily Oster:But I believe that fiber, I have some evidence for this, fiber might be the nutrient that Americans are sub-therapeutic, like missing the recommended value on more than any other nutrient, right? Like protein, we talked about protein and the recommended protein intake, which is quite low because it's just the amount you need not to like waste away to nothing. Like almost every American is getting more than that. And then we argued that probably they should be getting more, but even the recommended amount of fiber, which is like 20 to 25 grams a day, According to NHANES, the mean U.S. fiber intake is 17 grams a day.

37:45Emily Oster:So most Americans are below actually the recommended fiber intake. So we're bad at this, at fiber maxing. I don't find that very surprising actually because it's not that easy to add fiber to stuff. Most of the things we do in processing food take fiber out of it. And just putting it back in is not as easy as just making stuff with protein, I think. Oh, my God. What a good definition for ultra-processed foods. Not the official definition by any stretch, but taking the fiber out to make everything easier to eat and digest. Yeah. High energy density. But fiber comes actually in two types. It comes in soluble and insoluble fiber and also fermentable and not.

38:32So I guess there's like a two by two box of this. So soluble fiber is like it gels. It's like oatmeal, like gels things together in your stomach and it slows the process of things through your through your gut. Insoluble fiber is like like wheat bran and or, you know, any kind of like a husk, any type of husk of things. And that's like nature's broom. I think that's what people think about more. It sort of like flushes it all out. And that's the stuff you see in whole form in your poop a lot of the time.

39:08Emily Oster:Yeah. And this explains why doctors will recommend fiber both for constipation and for diarrhea. And they'll often not go into detail about like which fiber they're talking about, but it's that insoluble fiber, you know, cellulose, weepran and stuff like that, that is just going to transit right through. Those are non-fermenting, which means they don't cause gas formation, which a lot of people don't like when they are taking in fiber, right? So like looking for a non-fermentable insoluble fiber is kind of going to clean you out without causing too much gas. That's good for constipation. A soluble non-fermenting fiber is actually going to slow things down.

39:45Emily Oster:So when you're having kind of loose stools and you want to bulk up your stools, that's something like psyllium would be a prototypical supplement there that doesn't cause gas. And then we have all the fermentable fibers like resistant starch and all the things on the FODMAP diet that we talked about a few episodes ago, which are good sources of fiber, but the bacteria in your gut will ferment them and that generates gas. And then you have farts, which maybe that can be our next episode. Just like, let's keep going. What's the deal with farting? what's the deal uh good sources of fiber include beans beans have a lot of fiber chia seeds have a lot of fiber oatmeal has a good amount of uh of soluble fiber so uh there are a lot of ways to get fiber but they mostly are in the form of whole foods and fruits and vegetables yeah you gotta eat your fruits and vegetables kids we you know you see a lot of health claims about the benefits of fiber beyond, like it'll keep you regular.

40:46Emily Oster:And I think there's a fair amount of support for this. I anticipate Emily is not going to be as gung-ho as I am, but she's already rolling her eyes. All right. I have strong observational data from multiple studies that higher fiber intake can reduce the risk of cardiovascular disease and stroke, as well as... I'm using causal language, which you're going to yell at me for. Higher fiber intake is associated with a lower risk of colon cancer as well. Emily, you're going to say, I predict that, well, people who eat a lot of fiber do a lot of other healthy things, and that's why they are healthier in the long term.

41:30Yeah. That's what I'm going to say. And randomized trial data has actually not supported some of these colon cancer claims.

41:36Emily Oster:That's a very hard trial to do, because we're talking about fiber intake for 20 years. I agree. I agree. This is a hard question to answer. And I think part of my issue with this literature is your people say, oh, this is such a strong set of things because we have this Lancet paper and it's 135 million person years. But the thing is that when you add data, but it has all of the same biases, you haven't fixed your causal versus correlation problem. You've just made your correlations more precise. It's very, very clear that more fiber is associated with good health outcomes, but that is very different from saying that it is a causal link.

42:19And I don't think the causal evidence there is especially good. And we don't need to revisit my feelings on this in every episode, although we should. I like it. It makes

42:29Emily Oster:me feel like I'm coming home to a nice warm sofa. There's not even any Mendelian randomization in this one. Well, if there was, I would use causal language. Bummer. Bummer. Just to really piss you off. The last thing I wanted to say about fiber is that you actually do need hydration to make your poop work with your fiber, but more hydration isn't more helpful. So fiber tends to be like when you add it, your poop gets better. You need to be adequately hydrated to appropriately poop, because as your poop moves through your colon, it like pulls water out. And if you don't have enough water, it will like prioritize pulling the water out for other bodily functions and then leave your poop all dry and gristle type one rabbit pellets.

43:13But just drinking and drinking and drinking and drinking and being like way more hydrated than you need to be is not gonna make your poop nice. All right, get my water bottle with me. All right, wait, I wanna say two more things about how people poop good.

43:27Emily Oster:Oh, yeah, yeah, yeah. Yeah, besides fiber. There's more than fiber. There's more than fiber. One thing is the squatty potty. Do you have a squatty potty? No, I don't. Oh my God, you're missing – what is wrong with you? I know. Well, I didn't know the data and then I did the research and now I'm like, I don't know. Squatty potty. Tell me about it. Squatty potty is great. So the squatty potty is just a thing that you put under – it's like a piece of – it's like a plastic stool and you put it around your toilet and you put your feet up on it and it changes like your posture. It basically puts your knees up and it makes your colon, like, I don't know, straighter or whatever.

44:04It's more mimicking a, like, squatting posture, which is the way people pooped before we got toilets. And there's randomized data, actually randomized crossover data where they have people poop in both ways. And this improves the sense of complete emptying by, like, three times. and it reduces the straining by a lot. And this is very cheap and the effect sizes are big. And I really, really think that you should get one.

44:35Emily Oster:Do you have one? Absolutely. We have multiple. I have them on like all of my toilets. I'm not an idiot. Yes. I'm an idiot. I want to file this. So, okay. So I was seeing some crazy stuff online of, okay, this is gross, but people being like, if you're really poop maxing, you shouldn't have to wipe. Okay. And that's gross, first of all. That's gross. But one of the arguments is like, animals don't wipe. And that is true. It's not the most compelling. I used to have this cat that didn't wipe and it always had poop all over its butt. So I'm just not getting into this. One of the things though, so why I do these deep dives for this podcast, I don't know.

45:21Emily Oster:It shows that something's deeply wrong with me. But I went to a little bit of evolutionary biology. And it turns out that one of the reasons we have to wipe is because we walk erect. It's like we can add it to the checklist of things that because we evolved to walk erect, which gave us use of our hands for tools, that was very nice. And maybe like seeing over some high grasses in the African savannah or whatever else it was. We condemned ourselves to like a life of back pain, a birth canal that is all jacked up and high maternal mortality and the need to wipe our poops. And apparently there's evidence that humans have been wiping their poop since like before cibillus, before we had paper, before we had anything.

46:04Emily Oster:So it's not like that animals are doing something right and we're doing something wrong. It's we should never have stood up in the first place. and maybe the squatty potty corrects that just a little bit. I'm not really sure that's what the squatty potty does. And you still have to wipe. Yeah, no, keep wiping, people. Keep wiping. People don't stop wiping. Also, I do have one of those bidet seats on my toilet, which is a total game changer, I will say. I love it. Okay. It's nice. The other thing is you should not use your phone on the toilet because it encourages you to sit for too long. That is insane.

46:45Then you get hemorrhaged.

46:46Emily Oster:You're crazy. I realize this is a stupid thing to say, and many of us use our phone on the toilet all the time, and I don't, but it is, I think a different way to say this is there have been some studies associated with that show that people use their phone, you just sit for too long. So using your phone briefly on the toilet is fine, but if you're just like sitting and sitting because you're trying to avoid your family and scrolling on your phone on the toilet, You should get off the toilet and sit in a different part of the bathroom and pretend that you're on the toilet because otherwise you're going to get hemorrhoids.

47:17Emily Oster:Yeah, I saw that study and I think it's right, but it is very hard. I will say if I like forget my phone, like if I leave my phone in another room and I'm on the toilet, I am desperate. Like I will grab a shampoo bottle and read the ingredients. You can't be alone with yourself. What does that tell us, Barry? I cannot do it. I can't just sit quietly with my thoughts. or for like the 12 seconds that it should take. Actually, you know what would be better if you get a squatty potty, be going faster and then you wouldn't be so bored. All right. Squatty potty, hook me up. Okay. So knees up, phones down, eat your fiber, drink some water, have some coffee.

48:01That's like the practical stuff. But the more like fun, sexy piece of this is the, is the microbiome and the idea that this exciting constellation of bacteria and fungi that are living in us are really important for a lot of things. I feel like the microbiome had like a big moment like a couple of years ago. And now I kind of like the every episode of The Economist had a thing about the microbiome. I feel like it's like died out a little bit. Oh, I mean, the medical

48:30Emily Oster:side, it's still like, oh, you guys are still really into it. Oh, yeah. Great. Excellent. So So what is this and why are we thinking about it? Why do we care? Okay. So everyone knows there's bacteria in your stool, but it's more than just there's bacteria. It is an ecosystem. There are thousands of types of different species of bacteria that live in your gut, that live in your colon. They're all interacting with each other. They're digesting food for you. They are releasing substances that are absorbed into your body. Without them, we would be very sick. These are symbiotes that live within us.

49:15Emily Oster:People often ask, you'll hear statistics like, how much bacteria do you have in your colon? I have 10 pounds of bacteria. That's not true. You have 0.2 kilograms worth of bacteria in your colon. That's about an apple's worth of bacteria, but that's still a lot because bacteria are very small. So the way most microbiome studies work is you take a stool sample that is sent to a lab under varying conditions. There are some problems with these studies, and it's mixed up. And labs will do DNA sequencing for a bunch of different known bacteria. So every bacteria has a short sequence of DNA that's kind of unique to it.

49:52Emily Oster:And it's just like, okay, if we find this sequence of DNA, we can therefore infer that this particular bacteria was in the stool. And you do that for a bunch of different hundreds or even thousands of different bacteria, and you can see the relative amounts of bacteria in someone's stool. And basically everyone has about 14 genuses. They're the same 14 genuses of bacteria that sort of like the human stool microbiome. But that like vastly underestimates the amount of diversity from person to person. So in a study of 4 ,000 people looking at their stool microbiome, 75%, so 3 ,000 of those 4 ,000 had at least one bacteria type that was not found in any other person.

50:39Emily Oster:So the chances are you have a bacteria living in your colon that at least, you know, in your town, there is no one else who has that particular bacteria. And that seems nice. That's super cool. Is that nice? Right. I feel like I would want to know my personal bacteria a little bit better and like talk to it, see how it's like in life. So people's microbiome is in that sense quite person specific. So actually like you can identify even a year later, people have shown like you can basically re-identify like 80 % of people a year later by various like aspects of their microbiome. Having said that, There's actually quite a lot of individual over time variation within an individual in your microbiome.

51:28So it's not like you have one kind and exactly the same number of bacteria all the time. It's moving around with various aspects of your life.

51:36Emily Oster:It's moving around a ton. And I don't think people appreciate the amount of within-person variation. So for example, a lot of the wellness microbiome influencers will talk about certain species of bacteria and the relative abundance of something like acromantia or whatever, like your acromantia is too low. You need to take this supplement that I happen to sell to boost your acromantia. And any individual bacteria might vary in terms of concentration by tenfold between one day and the next day. So it's very different saying, taking the entire sum of bacteria, we can re-identify you from a data set, sort of like, oh, everyone has kind of unique fingerprints, than to say, oh, the particular whirls on your fingerprint are causing health or disease, right?

52:28Emily Oster:The fact that many people are surprised at is there is no reference microbiome. There's no good yet. I mean, this is the thing about this. People are like, make your microbiome great. By what? How would I know if it was great? Who is the guy? Who are we aspiring to be? with the best microbiome. What is Brian Johnson? I mean, we probably do know what Brian Johnson's microbiome is, but is that something to aspire to? I don't know. There is no optimal here the way there might be in some other things that we might measure. Yeah. What's his name? Brian Johnson's microbiome is probably screwed up because he has autoimmune gastritis.

53:08Emily Oster:So I don't think I want his microbiome. Fair enough. Yeah. So these things are shifting around a lot. It is unique to you. The primary driver, I mean, people will tell you, oh, it's what you're eating and your health lifestyle behaviors, it's going to change your flora and your fauna inside your gut. The primary driver in all of these studies that does repeat testing, right? So the same person, like what is causing change here is, callback, transit time. That seems to be the thing that changes your microbiome and that makes biologic sense because the longer stool is sitting in there, the more oxygen is getting taken up by aerobic bacteria.

53:51Emily Oster:So the oxygen levels are going down. And then the anaerobic bacteria, the bacteria that don't need oxygen to grow, start growing sort of later in the process. And so there's these dynamic shifts. There is some associational data that a greater percentage of anaerobic bacteria are associated with some worse health outcomes than aerobic bacteria, that might argue that shorter transit times would be better. Or maybe it argues that having a diet that promotes short transit times is healthy. Because it has a lot of fiber in it. Right. And the bacteria are just sort of like a side effect that are kind of moving around based on that exposure.

54:36So this for me is like the core issue with this microbiome stuff, which is like it is crystal clear that the microbiome varies across people and that it plays a role in our lives, right? And we can talk about this in a second, but like getting rid of your microbiome would be an extremely bad idea. We definitely are using that. But that is totally different from saying like, this is a thing where changing it, even if you know how to do that, would necessarily have some positive health outcome or knowing in more detail, like how would I change it and what would I want to achieve? And that could be different for different people.

55:15That's the other thing. It could be like my optimal microbiome is different from your optimal microbiome.

55:21Emily Oster:Totally. Certainly that's true. Yeah. We know that's, well, do we know that? I guess we don't know what an optimal microbiome is, so I don't know. But I even want to hammer home one more time that we don't really know whether the readout of bacteria in your poop is a result of your health or that the bacteria in your poop are causing health changes. So for example, like let's just talk about what you'll hear when it comes to microbiome. So you'll hear that there's a, I'll sometimes call it a dysbiosis pattern, right? So no researcher worth their salt is going to tell you that any one type of bacteria in your stool is good or bad.

55:59Emily Oster:I mean, obviously, if you have like salmonella, that's bad, but you know what I mean? Like they're not going to tell you that like, oh, this particular, you want this higher, this lower, whatever, but they will use very complicated statistical techniques to identify patterns. And they've found patterns that are associated with things like inflammatory bowel disease, colon cancer, obesity, and other metabolic diseases. To me, a common thread in this dysbiosis pattern is that inflammation in the colon leads to decreased oxygen tension, which leads to increased anaerobic bacteria. So I can tell a story where you have inflammatory bowel disease for some other reason, cause inflammation, that inflammation changes your gut bacteria.

56:43Emily Oster:We read that out of your poop. Fine. Gut bacteria, nothing to do with it. They're just, they are enjoying the environment in which they live, the anaerobic environment in which they live. Here's another story that's consistent with that data. For whatever reason, you got colonized with more anaerobic bacteria because, I don't know, you've eaten wrong and you didn't get enough fiber or whatever. Those bacteria release substances that angry up your colon, which then becomes inflamed and gives you inflammatory bowel disease. That's the state of observational data right now. And the only way to sort of figure out causality here is to do fairly dramatic things to try to change the microbiome in a human and see, like, does it change their health?

57:25And this is a place where I think the start of some of this microbiome is based on a really, really compelling set of very specific data. So there's a condition called C. diff, which is a very debilitating diarrhea disease that people can get. And it's like a recurrent, persistent infection that can be really, again, sort of really terrible. And it turns out that fecal transplants, transplanting healthy stool into the colon of somebody who has this is incredibly effective at treating this like much, much, much more effective, like 80 to 90 % resolution versus standard antibiotics, which have a pretty low effect.

58:18This is like, this is the way that you treat this disease now effectively. Yeah.

58:22Emily Oster:Recurrent C. diff, you know, and this makes sense because C. diff, clostridium difficile can colonize your gut when the other bacteria in your gut are killed. Like most people get this after taking the course of antibiotics. It's often a hospital acquired infection. You get antibiotics, that kills off all your quote unquote good bacteria in your gut, C. diff takes over. And you need to get those good bacteria back and healthy stool has those good bacteria in it. So yeah, fecal microbiota transplant, pretty awesome. Endorsed by every major society for recurrent C. diff. And this has been explored then in treatment of similar things like IBS, which the other is a little more mixed, ulcerative colitis, but places where it It seems like there's something going wrong in the sort of stool transit system that might be impacted by changing the bacteria.

59:13All of this other shit that people tell you, though, this is actually not supported. So there's this sort of idea like, OK, well, if taking someone with a really serious illness and putting somebody else's poop in them is going to fix that illness, then maybe you would just generally get healthier if you took some capsules of bacteria. But like those are not the same activities at all.

59:37Emily Oster:A hundred percent. And it's that theme again where wellness influencers start with biologic plausibility and it's there. There is biologic plausibility here. And then they just jump to let me sell you this product without any of the steps in between. And when you look at those steps in between, you find that that stuff doesn't work. So maybe, I mean, should we talk about probiotics for a minute? Yeah, let's talk about probiotics. All right. What do you think? I will give you three things that probiotics have been definitively established to be useful for. Everyone ready? All right. And by the way, multi-billion dollar industry out there.

1:00:24So huge industry.

1:00:25Emily Oster:Here are the three things. preventing clostridium difficile while you're taking antibiotics. Okay. Okay. Necrotizing enterocolitis in premature infants and pouchitis, which is an inflammation of the distal ileum in people who have had a colectomy. And that is it. The American Gastroenterological Association specifically advises against probiotics for inflammatory bowel disease, irritable bowel syndrome or kids with gastroenteritis. It's disappointing. Which is what everyone is using this stuff for. Yeah. I mean, yes, those are all the things people use it for. Yeah. I mean, there are some reasons to think that this wouldn't work.

1:01:12So, you know, there's some reasonable evidence that the probiotic for many people just never colonizes, like just gets sort of eaten by other bacteria. The other thing is probiotics. Yeah, digest it. The other thing is these probiotics are just a bunch of different random stuff. And even if your problem was that you were deficient in something that was causing some symptom, it's not at all clear that just taking the random probiotic that they sell at CVS or whatever was going to fix that particular set of issues.

1:01:45Emily Oster:Right, right, right. It would be like someone saying, you know, you should take an antibiotic for that. And it's just like, oh, okay, there's a lot of different antibiotics. Which one? And then, of course, you know, saying that, there are plenty of influencers and naturopaths and people who will tell you exactly which specific strain of whatever and no doubt sell it to you as well. And I'll just say there's no robust data for any of them. You can actually pay people to test your stool and then sell you the stuff that will fix it. And what's so great is that when researchers have done this, they actually sent this one paper where they sent the same poop to a bunch of different companies.

1:02:30And they all like a lot of them just came back saying different random things. Like, you know, they counted them differently wrong. Somebody said it was healthy. Somebody said it was it was unhealthy. you know, companies disagree with themselves. And then they're like, here's the supplement that you need to fix this problem. It's like,

1:02:48Emily Oster:it sounds like a great, great business. Amazing business. $400 to test your poop. Plus you buy our supplements. It's I'm minting money. Where do I invest in this? Yeah, no, I mean, this is the direct to consumer world. And it has all the trappings of science. And it's just, it's, it's probably, this is a very complicated area. The testing is not easy. By the way, when you send poop in the mail, the bacteria isn't dead, right? Like it's going to continue to grow. So it'll change based on the temperature that it's sent at. Not, you know, a lot of these are sent at room temperature. It'll change based on how long it takes to get to the facility and when they're actually testing it and stuff.

1:03:30Emily Oster:It's just, there's no valid way to, to do this for, for health and clinical. Let me ask you a question. Do you think – what share of these companies do you think are just getting the poop in the mail, throwing it in the trash, generating like a random set of data, and then telling you to buy their supplements? You think it's like half? No. Or no. I don't think it's outright fraud. Well, the testing is not – like this is routine PCR testing. Like it's not expensive to do. It's hard to do directly. I know, but it's just like you have to open up these boxes of people's poop that they ship. I don't know, man.

1:04:03That feels like outright fraud to me.

1:04:05Emily Oster:I don't know. I like to believe in the inherent goodness of humankind. Wellness grifters. You like to believe in the inherent goodness of grifters. Okay, that's awesome. Self-interestedness. There's one microbiome study, and this is a little far afield, but I think it's such interesting science that I did want to bring it up, and that's the discordant twin obesity poop study. Can we talk about this? Yeah. Yeah, but in human twins. Oh, in humans, yes, yes. Yeah, talk about it. I think it's a cool study. Okay. So this is a study that prompted people to begin saying that obesity is a disease of the microbiome, that we can fix the obesity crisis by somehow changing our microbiome.

1:04:50Emily Oster:And it's a really fascinating study appearing in science in 2013. It's a very small study. Emily points out it's largely in mice, but hey, it's worth talking about it because people mention it. So what they did is they took four female twin pairs who were discordant for obesity. So one of the twins had to have a BMI greater than 30 and the other couldn't, and they had to have at least 5.5 BMI points between them for at least several years. So they were really, they were like different. By the way, only one of the four twin pairs were identical. The other, you know, the other three, it would be very hard to find identical twins that were this discordant on obesity because so much of obesity is driven by genetics.

1:05:29Emily Oster:So whatever. So three of the pairs were dizygotic, fraternal twins. Okay. But then what they did is they took germ-free mice. So these are mice who have no bacteria. They're raised in a germ-free environment. I think they're even birthed by C-sections so as not to be colonized by their mom's vaginal flora. So germ-free mice. And they gave them fecal microbiota transplant from each twin and let them eat whatever they wanted. And the mice, given the obese twin feces, gained more total and fat mass and developed metabolic complications associated with obesity, like elevated blood sugar and things like that.

1:06:09Emily Oster:Whereas the mouse that received the other twins just developed like a normal mouse. So sort of a compelling study to suggest that something is going on with the bacteria there. Are they releasing something that's encouraging more eating behavior? Are they slowing the metabolism by secreting some bacterial metabolite? We don't know. Interestingly, when they mixed the mice together in the same cage, so the lean mice and the obese mice were put in the same cage, the obese mice lost weight. And the reason they lost weight is because they ate mice that ate each other's poop. That's like a mouse behavior.

1:06:47Emily Oster:And so the obese mice ate the poop of the lean mice and the lean mice ate the poop of the obese mice, but apparently lean microbiome dominates and the obese mice lost weight. Now, I can't think of any reason that this isn't 100 % applicable to human beings. Can you? I can't think of anything, but it turns out the experiments, they're difficult to recruit for the experiments that ended poop eating. And so they haven't, for that reason and many others, perhaps, this is actually, they've struggled to replicate this in humans. And so this hasn't, not for the reason I said, but for other science reasons.

1:07:27So this hasn't kind of led to some microbiome related treatment for obesity.

1:07:32Emily Oster:It hasn't. And there have been randomized trials of probiotics for obesity and they have really no effects. It doesn't seem like that's the driver in humans. But it is very interesting. Yeah. All right. My big picture takeaway on the poop here is that actually you should be paying some attention to your poop. If for no other reason than like having a nice poop every day and not being constipated or having diarrhea really improves your life. Yeah. I think for most people like that's just like that is a part like if every morning you just had one nice poop and you didn't worry about it for the rest of the day like that's good.

1:08:10That's a good way to start your day. And there are some ways to make that more possible. But that is different from saying once you are at that, you're maxed. That's the poop max. There's no further poop maxing from there, I think, that we need to be doing. That's at least my take.

1:08:25Emily Oster:I think you could not have said that better. That's my hashtag poop goal. And I think I'm pretty close. I think I'm pretty close to being there. But maybe I need to eat more fiber like every other American. No, you need to get a squatty potty. I don't understand. Just get a squatty potty. Okay. Squatty potty coming right up. All right. Well, so I think I know where you're going to be on this, Emily, but smash or pass poop. Smash on poop. Smash on poop. I agree. I'm thankful for poop and more importantly for regular poops on a Bristol stool scale of three to four. Totally. All right, that's it for poop.

1:09:11Your mailback question of the week after the break.

1:09:16Emily Oster:We all miss the 90s, the music, the shows, the outfits, and without a doubt, the snacks. Simple Mills is bringing back the golden age of snacking. They taste delicious, like the snacks you grew up with, only they're made with real ingredients like watermelon seed flour, almonds, cashews, flaxseed, and organic coconut sugar. Fancy. You'll love the throwback taste of Cheddar Pop-Ums, the nostalgic flavor of mini crunchy chocolate chip cookies, and the familiar crunch of honey cinnamon sweet thins. Available in snack packs that are easy to toss into lunchboxes, backpacks, or your own bag. Simple Mills snack packs are simply the coolest.

1:09:55Emily Oster:Simple Mills. Throwback taste. Grown-up ingredients. I'm Martha Stewart from the Martha Stewart Podcast. In this special episode brought to you by McCormick Signature Seasonings, I got to chat with Reddit founder Alexis Ohanian about his new venture, Retrieve Air. We also get to talk about his family life and playing the weekend chef. I'm a simple man. I use honey from the farm and I got my crepe. That's it. The girls like their Nutella. That's my breakfast ritual. I'm usually phoning in lunch a little bit because I'm really planning on a delightful dinner. The girls really like steak. I spoil them.

1:10:32Emily Oster:So even if I'm doing kebabs, I'm using ribeye, I'm doing it right. Okay, well, please. Listen to the full episode of the Martha Stewart Podcast wherever you get your podcasts. I thought I looked so cute. I pieced together a cute outfit. And this girl comes up to me, just sits next to me, telling me, oh, hey, girl, I see your skin. I know what you're suffering with. I just remember feeling so just, like, distraught and, like, robbed of my time. When I finally freed myself of that conversation, The lights were coming on and the party was over. It felt like I had a sticker on my forehead that said, she has eczema.

1:11:14Emily Oster:We've all been there, wanting to go out, feeling cute, forgetting about all your problems, and just existing in the present with joy. But when you live with a visible skin condition, that can be a lot harder than it needs to be. This is Skin Queries. Listen on the iHeartRadio app, Apple Podcasts, or wherever you get the stories that make you feel understood.

1:11:41Emily Oster:And now for our question of the week. By the way, if you have a question for Emily and I, reach out to us at wellnessactually.fm. We would love to hear from you. All right, let's play it. Hi, Emily and Perry. This is Jamie from Boston. And my question is about all the water that everyone is supposed to be drinking all the time. I feel like if I don't have my water bottle with me, I might die of thirst. never mind my preschooler who always has to have her water bottle at school. We didn't have this in the 90s when we were drinking from those unrefrigerated ceramic water fountains. Did water become more important?

1:12:16When did that happen? Why? Okay, thanks. Okay, Perry, you are a kidney doctor who grew up in the 1980s. So what is going on with the excessive hydration that's occurring now?

1:12:30Emily Oster:You're not going to like what I say. Drink more water is such an easy bit of wellness advice, especially living in a country with robust access to healthy water supplies and with good water bottles. The truth is that most people get a totally adequate amount of water. So physiologically, I know, I know, no one's happy. Everyone's upset. Okay, listen. Physiologically, thirst is one of the most powerful sensations that animals have. We become thirsty when the level of sodium in our blood, which is normally 140 millequivalents per liter, rises to about 141 millequivalents per liter. So as the water is gone, the sodium gets more concentrated.

1:13:20Emily Oster:141. At that point, your brain is kicking in and you will find water. The only time that doesn't happen is if someone's incapacitated and we'll see people with high sodiums because no one's giving them access to water or if they have rabies and have hydrophobia. Your urine puts out water. It's mostly water. And it can dramatically vary the amount of water that it puts out. So you can put out about 20 liters a day of water in your urine if your kidneys are healthy. So if you're drinking 10 liters of water, you know what? you're just going to pee that right back out. And it doesn't do anything special.

1:14:01Emily Oster:It doesn't help your kidneys. It doesn't like kind of clean them out. One exception is if you're prone to kidney stones and having more dilute urine might reduce the risk of recurring kidney stones. I have to say that. But like beyond drinking when you're thirsty, there's not great evidence that drinking water that frequently improves your health. Sorry. That's okay. Those of you not watching this on YouTube or a video platform, I wish you could see the faces that everyone, God, everyone hates nephrologists. You're boring. And I feel that people are water maxing and you're trying to, you know, like, I mean, first of all, do you have an Aula?

1:14:41Because my kids both have those and that's a great water bottle. Oh, I call it a Wala.

1:14:46Emily Oster:I do. My kids do have some. Yeah. And my kids do. I even like give my kids water bottles to go to school every day. They all have their water bottles. They refill their water bottles. I just like, from a health standpoint, I'm like, as long as they're given access to water, they'll drink when they're thirsty. And that is all you need physiologically. I do find we've gotten to a point where like occasionally if for some reason one of my children forgets their water bottle, like they sort of come home with this view of like, I almost died at school today. I didn't have my water bottle. All I could do was drink a small amount of water from the Rhode Island.

1:15:21We call it a bubbler, the water fountain. I had to buy water in a box because otherwise I would have died. But I guess what you're saying is they wouldn't have died that quickly.

1:15:32Emily Oster:Correct. I will say, yes, the data is like, you know, on like skin turgor and stuff, you know, and there's, there's, look, if it makes you feel good, that's great. That's totally fine. But I do think people maybe go a little bit overboard with it. You can drink too much water also. You can. It's, it's hard. Mostly happens when you're running. Yeah. Yeah. Yeah. Water without electrolytes can cause hyponatremia where your sodium is too low. So like you dilute your sodium and you really need the sodium in your blood to keep your brain and heart working. And the treatment of severe hyponatremia is very fun for nephrologists, but not very fun for the patients that we treat because that's one of our diagnoses.

1:16:18All right. With that, that's it for us today. Stick with us next week when we will ask, what's the deal with seed oils?

1:16:32wellness actually is produced in association with iheart media our senior producer is tamar our executive producer at iheart is jennifer bassett our theme music is by eric deutsch and our content is for educational purposes only if you like the show help other people find us

1:16:49Emily Oster:leave a rating and review on apple podcasts or your podcatcher of choice and help us spread the word about the show, you can follow us on Instagram at wellnessactuallypod. And don't forget, we want to hear from you. Head over to wellnessactually.fm and leave us a question for our mailbag or suggest a topic for a future show. We'll let the influencers have the last word. Hey, bestie, here's a little squatty potty hack to help you poop easier. So instead of keeping your knees wide, you're going to actually let your knees fall in and that's going to create a little bit of hip internal rotation. We're just going to open up the backside of the pelvis to give space for stool to exit our body.

1:17:29We're going to breathe it out. We're not going to strain and we're going to have a nice satisfying poop.

1:17:47Emily Oster:We all miss the 90s, the music, the shows, the outfits, and without a doubt, the snacks. Simple Mills is bringing back the golden age of snacking. They taste delicious like the snacks you grew up with, only they're made with real ingredients like watermelon seed flour, almonds, cashews, flaxseed, and organic coconut sugar. Fancy. You'll love the throwback taste of cheddar pop-ums, the nostalgic flavor of mini crunchy chocolate chip cookies, and the familiar crunch of honey cinnamon sweet thins. Available in snack packs that are easy to toss into lunchboxes, backpacks, or your own bag. Simple Mills snack packs are simply the coolest.

1:18:26Emily Oster:Simple Mills. Throwback taste. Grown-up ingredients. I am talking to a felon right now with face tattoos, and I cannot decide if I like him or not. That was a caller from my podcast Therapy Gecko, where I speak with anonymous callers about their problems, relationships, and anything else in the depths of their mind. It all happens on my show, Therapy Gecko. So if you're trying to get out of your own head and into someone else's, this is the podcast for you. Listen to Therapy Gecko on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. On August 4th, 1962, Marilyn Monroe died.

1:19:04Emily Oster:Then the rumors started, and she died again. And now, we're going to set the record straight and learn about the way Marilyn Monroe actually died. The third way. I'm Jake Brennan, and on my podcast, Hollywoodland, I revisit some of the biggest stories from Hollywood history, separating the myths people want to believe from the reality underneath them. Hollywoodland is part of the Exactly Right Network. Listen to new episodes every Monday on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. This is an iHeart Podcast. Guaranteed human.