We know that fiber is a main ingredient for creating a healthy microbiome. That's really not up for debate. (upbeat music) It's becoming more and more clear as time goes on that the microbes in our gut have way more control over our body's biological processes than we originally thought or might like to believe, including, as it turns out, immune system functionality, our resistance to infection and illness. If your complimentive gut bacteria are off and you don't have a healthy microbiome, your immune system might not trigger that release of virus slaying capabilities. To better understand this connection between our microbiome and our immune system, I sat down with Robynne Chutkan MD. Robynne is a board certified gastroenterologist who serves on the faculty of Georgetown University Hospital. She is the founder of the Digestive Center for Wellness, as well as the author of the books, "Gutbliss: Microbiome Solution," "the Bloat Cure," and her most recent, "the Anti-Viral Gut," which is the central topic of this conversation, and offers practical advice for optimizing diet, exercise, sleep, and time outdoors to boost the body's defenses and our overall health. Most of the immune system is physically located in your gut, about 70% to 80% of it, and there's constant communication, so the gut bacteria actually guide that immune response. They're constantly sending signals to the immune cells to tell 'em what to do. We've talked a lot about the microbiome on this podcast, but I would say that today's exchange is truly a masterclass within itself. We discuss how the gut is affected by birth control, sleep, stress, lifestyle, and diet, as well as various medications including NSAIDs like Ibuprofen, and PPIs like Prilosec, and we end with advice on how to seek treatment for a gut issue. I've known Robynne for a number of years. She is such a delightful presence, and it was a treat to have her here again for her second appearance on the podcast. Robynne's expertise in communicating on this subject matter is unparalleled, and I'm very excited to share this one with you. So, please hit that subscribe button and enjoy this deep dive into that anti-viral gut with Dr. Robynne Chutkan. (upbeat music) It's so nice to have you here. It's so great to be here. I was reflecting on the last time that we did this. It was a full seven years ago. I remember showing up at your house in DC and meeting your family, being very intimidated by your husband, who I believe is, like, in counter-terrorism for the CIA. Like, he's a super spy. He was with DHS.
Is he still doing that? He was with NCIS, and then DHS, so now he's with MiDAR, but he's just a pussycat. Do you remember my daughter? I think she was 10 at the time, and I remember you got out of a car, I think an Uber, and she was all like, "What, he didn't swim up the Potomac, "and bike, and run, and she was all disappointed "that you hadn't, like, come on foot." I'm a civilian, yeah. I can't believe how long ago that was. It feels like yesterday, but delighted to have you back. We're here because you've got this new book out. A lot has happened over the last seven years in terms of your life and also advances in the science of the microbiome. It really is like this amazing frontier right now where so much is coming out about how important gut health is for every facet of health. We're gonna focus on the immune system today, "the Anti-Viral Gut," your book, but maybe catch us up on what's going on in your life since we last talked, and maybe, you know, what's been going on in the field of microbiome science. In 2015, I think my second book, "the Microbiome Solution" had just come out and I think people were just sort of like, "Huh, what? "Gut microbes?" It was a new concept for everybody. I mean, obviously, we've known about the microbiome now really from the 1600s, when Antonie van Leeuwenhoek first looked at his own dental plaque under the microscope and saw some critters, but, you know, as you pointed out, Rich, it's really taken a while, and now we're in this crescendo phase, so there's a really cool graph online, it sort of floats around the Internet, of the number of medical articles, published scientific articles on the microbiome, and, you know, it's like a bar graph and then you just see it, like, stacking up, and now, of course, in the last two years, that's just gone through the ceiling, right? The scientific literature, and in some ways, the scientific literature has caught up with what we know to be true because we see it, we live it, we experience it all the time, and so, I actually have gone back and read that second book, which until this book, was the favorite of my four books, and realize, like, how much of that maybe just sort of didn't penetrate for people really until this pandemic, so it's actually kind of tragic that it's taken a global pandemic like this, in some ways, for people to really realize this stuff matters. And yet, I'm not sure I'm convinced that the pandemic really connected people with the importance of the microbiome and its relationship to the immune system. I mean, this is a big focus of the book, right? Like, I learned a lot reading it. I mean, first of all, fabulous job. I think it's--
Thank you. You know, an incredible read and I learned a ton, and on the subject of how science has advanced, it is like the new and the old, right? Like, you even have the quote in the book, like, Hippocrates saying, like, all disease begins in the gut. Like, this is not a new idea. All this science is coming out, and yet it does also feel like we're still at the starting line. Like, I feel like there's so much more that we still don't know that we're discovering. Like, every month something new comes out, some revelation about how important our gut health is in relationship to every other facet of wellbeing. And that was part of the challenge of writing this book, quite frankly, this idea of the science moving so fast. So, unlike the other three books, which are primarily about digestive health. I've been in this field for 30 years, I dare say I know what I'm talking about. This science was changing. I'd literally wake up in the morning, and there'd be, you know, 10 research articles for me to read, and by that night, there would be more, and then the next day, I would wake up again, and I remember commenting to my daughter who's now a senior in high school, I think she was probably finishing up her sophomore year when I started this process, and I remember commenting to her and sort of complaining that I feel like I'm writing a 20 page research article every day, and she very kind of sarcastically said, "Well, welcome to my world." Maybe she was a junior in high school, but it really did feel that way, but at the same time, it was incredibly exciting, because seeing these fields of immunology, and microbiology, and gastroenterology all coming together, neurology, quite frankly, coming together, and it also felt that there was a fervor, not just in the medical and scientific community, but out there with people to get answers and to find out, and you can see it's reflected in the publishing process and in the way that articles now are more accessible, and, of course, a peer reviewed process is important. We need to make sure, we need to validate when a new article comes out, that the statistics are correct, that the figures are correct. That peer review process is super important, but at the same time, it's super important to get the information out to people quickly, and I think this concept of the citizen scientist, you know, of, I mean, I'm just amazed at my patients, how much they know and how much they've read, and they're reading a lot of the same journals I'm reading. I mean, maybe they don't have the same scientific medical background to interpret it the same way, but they're interested. There's this kind of thirst and fervor to find out that just feels different from where we've been before. That can go both ways though, right? Like, you can have the person who goes down the wrong rabbit hole and gets a bunch of strange ideas in their head about what they should be doing. I mean... There's a lot of that.
That seems to be, you know, a big problem at the moment. Like, what is fact, what is fiction? And when you kind of peruse, you know, news articles that are extracting from the peer reviewed research, they don't always translate it properly and there tends to be click-baity headlines associated with that stuff that give people maybe misguided advice. Absolutely, and then there's a commerce piece. There have been huge fortunes made as, you know, from whatever it is, like whatever this sort of magic pill at the moment is for "curing" COVID, and as you said, the click-bait, you know, the sensationalism, the goal for me for this book was pretty simple. I just want to give people information that they can use, and the tone is it, you know, I feel calm and reassured. I mean, as time has gone on, I think we felt more that way. There was certainly, I think, a lot of terror in the beginning, and it's not just about COVID, it's about your body. The more you know how it works, the more you know that these things that are happening are primarily designed to help you, not to hinder you, and the more you understand it, and can have that dialogue, the better off you are, and that's true about COVID, about cancer, about, you know, the common cold, whatever it is that's going on, and really making sure that people understand some of the physiological, the anatomical, the hormonal processes that are going on. Sure, sure. Som the subject of the microbiome is not a new, you know, theme for this show. I've hosted many conversations on this subject matter, including yourself, and we did a masterclass on it not too long ago, but what we haven't done is really go deep into the relationship between gut health and the immune system, and obviously this is the focus of the book, so let's start with just defining our terms a little bit. Like, when you say... Okay, we kind of know what the microbiome is, we're gonna get into that, we kind of know what the immune system is, but, like, the immune system, it's sort of ephemeral, right? It's not like the pancreas, like, where is the immune system? What does it do exactly? It's dispersed to some extent. It's complicated. It's really multiple systems operating. So, talk a little bit about, like, what we mean when we talk about the immune system. Sure, and I think you did a fantastic job of describing exactly how people perceive it. It is this ephemeral, kind of, it's humors lurking around in the body somewhere, but most of the immune system is physically located in your gut, about 70% to 80% of it, and so, when we talk about the immune system, we do a little Immunology 101, and full disclosure, I'm not an immunologist, I'm a gastroenterologist, but let me give folks some basics. So, we're really talking about two systems. We're talking about the innate immune system that you're born with, and an acquired immune system, sometimes called the adaptive immune system, that you acquire over time. The innate immune system works quickly, but it's sort of non-specific. So, for example, if you get a cut, it works to help protect you from the bacteria that may be invading through that open wound, but in a very non-specific way. The acquired immune system develops over time and it actually keeps a record of every pathogen that you're exposed to, so that it can remember it and mount to response. So, it's sort of like that person who never forgets, and holds, a grudge, and is like, "Oh, yeah, "in first grade you kicked me onto the table." Like a crow, right? Crows never forget. Exactly. So, the acquired immune system is able to... It takes a little bit longer to work, and particularly if it's a new organism, but it remembers, and then it is able to release antibodies. So, the acquired immune system involves T lymphocytes and B lymphocytes, and the B ones make the antibodies and the T lymphocytes are kind of like air traffic control, destroying cells that have been infected, et cetera, but if you think about the adaptive immune system, the point that I'd like to make for people is that is a basis of vaccines, for example. A vaccine introduces a tiny little bit of the viral protein, not enough, ideally, to make you sick, but enough for your adaptive immune system to start to create antibodies against it for the next time it encounters that virus, and so, if you think about some of these things, like with measles for example, a virus that's very old, you get measles and you, you know, have the illness, your immune system remembers, so that the next time you're exposed to measles, you are immune. Now, vaccine can do the same thing, right? But so can having the disease in that particular instance, and so, what we see is that the adaptive immune system can make you less sick or not sick at all the next time you encounter something. Sure. So, the innate immune system, the acquired immune system. So, when we talk about, I think you said 70% of the immune system resides in the gut. So, what is it exactly that is in the gut? Is it these lymphocytes? Is it these, you know, systems and pathways? Like, what are we talking about? It's these actual cells. So, when you think about the gut lining, this is a razor thin lining. It is literally, you know, a millimeter or two thick, and it's a net, it's a permeable net, like a fishing net with tiny holes, and it allows some things to go through. So, typically digested food, digested into the micronutrients passes through, and then the excrement, the waste matter from cells passes out, and remember that when something is in your GI tract, it's not actually inside your body, it's in this long hollow tube from mouth to anus, and so, things get passed out. Well, the immune cells are on one side. They're on the inside part of the net, inside your body, and your trillions of microbes are on the outside, on the other side of the gut lining, and, of course, there's a thick mucus layer also surrounding the gut microbes, but it is literally this hand and glove relationship and there's constant communication. So, the gut bacteria actually guide that immune response. They're constantly sending signals to the immune cells to tell 'em what to do, and I'll give you, a great example of that is, there is a bacteria in the gut called bacteroidetes. It's a type of bacteria, and there are many different strains, and when certain viruses enter the GI tract, bacteroidetes in the gut lining right there, you know, in the lumen against the lining will trigger a message interferon, and they're called interferons because they interfere with viruses to release certain cytokines to destroy the viruses, and so, if your complimentive gut bacteria are off, and you don't have a healthy microbiome, and you don't have sufficient quantities, or the right strains of bacteroidetes, you might not trigger that release of interferons and the sort of virus slaying capabilities, if you will. So, it's both a functional relationship, and it's an actual physical relationship, Rich, because they're right there next to each other, constantly communicating, and when you think about it, your immune system, your gut lumen is exposed to trillions of different things, because, again, it's in contact with the environment, what we're eating and swallowing. Everything's going into this open tube, and your immune system has to look at this morass of, you know, a gazillion different organisms, and figure out what's friend and what's foe, and it's really the gut microbiome that is directing that, and that's literally saying, "Yeah, "this one, you need to be really worried. "Do something big. "This one, just ignore. "Yeah, this one's actually helping." So, it's that back and forth relationship, that communication that's happening all the time in our gut. So, essentially these things are completely interwoven. You can't talk about the gut without talking about the immune system, and vice versa. They're 100% dependent upon each other in terms of their functionality, and when we talk about immune system dysregulation, that can come in two forms. Either it's hyperactive, and then you see all of these, like, autoimmune diseases or allergies to foods, and such, the cytokine storm that comes with, you know, certain people who succumb to COVID, et cetera, or the underperforming immune system that you mentioned, where you're not producing the interferons and the cytokines necessary to combat the disease on the front lines, the virus on the front lines. Is that a fair--
Yeah, that's a beautiful summary, and I think even dividing it further into internal threats and external threats can help to clarify it even more, but you gave an a beautiful summary of what it is. So, if we think about an overactive immune system, on the one hand, I want people to think about internal threats, and that would manifest as autoimmune disease. So, that's basically when your body is reacting to your own body's normal tissue, it's recognizing your own joints, skin, et cetera, as "foreign," and mounting an immune response, and so, we see that with the autoimmune disease, effect one in four Americans, there are over 100 different autoimmune diseases now, and this is a list that's growing, unfortunately. We can talk about why that's happening later. When we look, still, in the category of an overactive immune system, we look at external threats, and so, that would be, people are having allergies, peanut allergies, severe allergies to bee stings. I was exploring the marsh Beaufort, South Carolina, my husband's hometown, back in May, and we had the unfortunate privilege of being bitten up by chiggers, these insects, and his healed in about two or three weeks, and mine are still active four months later. I've have this sort of unknown, delayed hypersensitivity reaction to it, and maybe because he grew up in South Carolina, and he's been bitten by chiggers before as a kid, and I never have, but that's an example of an exaggerated response to this external threat. So, that's all overactive immune system. Underactive immune system, if we, again, look at the two categories of internal threat and external threat, the internal threat would be people developing cancer because your immune system doesn't just protect you from infection, it also helps with cancer surveillance. So, as our cells start dividing, sometimes they start to divide a little precariously, and that reproduction leads to errors in the genetic material of the cell, and over time that can transform to cancer, and so, the internal cancer surveillance system is also something that our immune system does, and it would weed out those cells, so that they die off and they're not continuing to proliferate and form cancer. So, with an underactive immune system, your cancer surveillance is off, and you're at increased risk of the cancer on the internal side, and on the external side, that would be infection, viral, bacterial, fungal, et cetera. So, what what we are should all be aiming for is this concept of a Goldilocks immune system. An immune system that is active enough to clear a virus, but not so active that we end up with a cytokine storm. You mentioned this overblown immune response, and the really fascinating thing when we look at this pandemic is that a lot of the deaths and the illness have been due primarily to the immune response, not so much of virus itself, but it's our bodies unregulated or dysregulated response to that virus that's causing the acute respiratory distress syndrome or other severe illnesses, and sometimes even death. Yeah, sure. So, there's so much in what he just said to unpack, but to kind of pull some threads on this, I mean, first of all, yes, in this era of COVID, I think we can all agree that we've been on the receiving end of a lot of conflicting information and social vitriol that kind of swirled around, what is fact, what is fiction? Certainly, you know, one truth that was kind of underrepresented was that there was not enough messaging about the personal responsibility that we have for our own health, and much of what you talk about, and is in your book is the malleability, the adaptability of the gut microbiome, and, in turn, our immune system. When we sort of get rid of certain things or stop certain habits and adapt new habits, it really is resilient in that regard, and we're all capable of, you know, creating a Goldilocks immune system. I mean, most of the languaging is around boosting our immune system. Obviously, that's problematic for the reasons that you just said. It is this Goldilocks immune system that we're all striving for, but to kind of begin to understand this, I think we have to talk about, it seems to me that the first place that we want to kind of enter into here is the difference between Germ Theory and Terrain Theory, which you, you know, beautifully articulate in the book. So, let's start with that. Okay, and I can talk about that one for hours. That's a great one to talk about, but I just want to circle back to something you said, which I think is so important, which is this, you know, perceived duality that if you're saying host health matters, and that we have some control over outcome, that means that somehow you're not saying that vaccines and monoclonal antibodies, and so on are important, and I just want to sure emphasize that both of these things are important, and it's common sense, not just--
It's not a hard thing. I don't why for people insist on it being either, or. I mean, if you're an 85 year old with heart disease, who's a smoker, and sedentary, and overweight, and diabetic, and hypertensive, and you have a heart attack, you're gonna do worse than somebody who's 35, and, you know, an ultra runner who eats really healthily, et cetera. So, host health matters for cancer, and infection, and viral illnesses, and everything else, and that's the goal, to be the healthiest host we can. So, to get back to my two favorite topics of Germ Theory and Terrain Theory. Germ Theory was really popularized by Louis Pasteur, and Germ Theory basically says that a bad bug gets into your body, and it makes you sick, and that's absolutely true, and we see evidence of that all the time. We're seeing evidence of it now with SARS-CoV-2, but Terrain Theory says that a healthy host can manage illness and recover, and that's also true. So, we wash our hands. If you look at medical practices, you know, we wash our hands and we sanitize things because of Germ Theory, but we also eat a healthy diet, and exercise, and do all of those things because of Terrain Theory, because we want to be healthy hosts, and so, the two things are really, you know, again, they're hand in glove, they're not contrary to each other, and, you know, in the scientific community, there was all this back and forth, but, apparently, Antoine Bechamp, who popularized Terrain Theory, who's also a Frenchman like Louis Pasteur, folks, in the Bechamp camp, and I don't think they're two distinct camps, and they shouldn't be, but they sort of are. Apparently, Louis Pasteur, reportedly on his death bed said Bechamp was right, Terrain Theory. (laughs) I don't know if that... That might be a little dramatized, but clearly both things are really important. There are germs that get into our body, that can do us harm, but our health as hosts matters greatly in this equation, and it's also important to realize that not all germs are bad, and a scorched earth approach, where we, you know, go out and basically try and, you know, seek and destroy mission for all bacteria or viruses can lead us to some bad places. Right, once again, it's not a binary dualistic thing. It's not one or the other. These are both important. It does feel like, in the messaging or conversation around COVID, it was pretty much all about Germ Theory and maybe not enough about Terrain Theory. We can quibble about that, but it is interesting to consider the interplay between these two, you know, theories that are at play in terms of our susceptibility to a viral infection and disease, and what was amazing in the book was the statistics around people who were not healthy hosts, or who had dysbiosis, or some kind of dysregulated gut microbiome, and how they ended up faring when they came into contact with the virus. Yeah, it's an incredibly predictive marker, the health of the microbiome. So, one of the studies that I talk about in the book is a study that looked at what's going on in your microbiome as a predictor of acute respiratory illness, and even death, and the accuracy of identifying these different organisms, and the one in particular, faecalibacterium prausnitzii, that's really this incredible bacterium that's associated with eating a lot of plant fiber, and protective for other reasons in terms of short chain fatty acids and immune regulation. High levels of faecalibacterium prausnitzii were very predictive of a good outcome, and low levels, the opposite, and the accuracy in this study was 92%, which is much higher than looking at age, gender, comorbidity, or even inflammatory markers like the C-reactive protein, et cetera. So, they were seeing really incredible correlation between this marker of a healthy microbiome and outcome from COVID, and that's true for other viral illnesses also. We've seen similar statistics for influenza, for rotavirus, et cetera, and again, we shouldn't be surprised by that, but somehow we are, When I would watch reports on television, and I think we'll look back at this time and see a lot of things we didn't do right, and one of that was the television reporting, which was really designed to just completely freak us out and terrorize us, make us scared, and I would look at it with my family, and would say, you know, I bet you this person is taking an acid blocker, has obesity, is, you know, maybe on an immuno compromising medication, et cetera. So, again, there is predictability to this, not 100% of the time, of course, but there are patterns that we see when we look at some of these factors, host factors that are the primary determinants of outcome. It's not the virulence of the virus. When we take a population of people who are exposed to the same virus and we look at different outcomes, those outcomes are all exposed to the same virus, those outcomes are very much dependent on what the individual host factors are, and many of those are things that we can mitigate, we can do things about. Yeah, I mean 92% is quite remarkable, right? It's pretty damn good.
And that's without considering any other factors. When you actually then fold in, you know, some comorbidities, I think the statistic I saw is that it goes up to, like 98%, predictability. 93%. Is that what it is?
Yeah. Yeah, you get an extra percentage point. So, in other words, we all know people, or just, you know, the general case of, like, "Well, this person, you know, "ended up in the ICU," it doesn't have to be COVID, whatever disease, right? This person got exposed, and they ended up violently ill, and this other person who was standing right next to that person didn't become symptomatic at all. Why is that? And we just, "Well, who knows?" Like, genetics, or we just sort of dismiss it, and what you're saying is, no, actually when you look at the gut, it becomes quite clear why some people fare better than others. Absolutely. And these other co-factors, obviously. And it's important for people to understand there's not blame being assigned here. We're not saying, you know, you got sick and ended up on a ventilator because you have obesity and that's your fault. The whole point of this is to recognize that these are factors that we can identify that can help us prognosticate, and more importantly, that we can remediate, ideally, so that this doesn't end up happening to you again, or you recover. So, you know, it's important for people to understand that this is not about blaming the victim. Somebody gets sick from COVID regardless of their circumstances. It's tragic, but it's really essential to point out and to identify, what are these factors? So that we can do risk mitigation and also maybe we can think about our strategies for how we approach our next pandemic. Who's at high risk and who's not, as opposed to just, you know, blanket recommendations.
Blanket policy to everybody. Yeah, yeah, yeah. Well, let's get into that. I mean, obviously, the key thing we want to avoid is dysbiosis. Dysbiosis is something that we've talked about extensively on the show with Dr. B, your peer, your colleague in this world.
Love him. Yeah. So, if you want to hear us go on for hours about that, you should listen to those episodes, but in terms of the causes, like, the primary causes of dysbiosis, I learned a lot reading your book and about certain things that I didn't know can be driving this, that are easily remediated. Like, let's start with PPIs, proton pump inhibitors. You already kind of referenced it a moment ago, but I was not aware of this. Yeah, you started with my favorite one and I'll tell you, Rich, a big part of the motivation for writing the book had to do with that pivotal study on PPIs, and I do use my husband as a little bit of a sounding board. So, I remember when that study came out in the summer of 2020, I said to him, because he's not in medicine, so he's, you know, I'm surrounded by a lot of medical colleagues and we all know a lot of the same stuff, but I said to him, I said, "You know that if you're on an acid blocker, "you're going to be much more likely to get COVID," and he was like, "What? "Why?" And I said, "Because stomach acid..." And he was like... But I kept saying, "Well, you know that, right?" And he goes, "I don't know that. "How would I know that?" And then I realized, not only did he, in a non-medical field not know that, a lot of my medical colleagues didn't know that, a lot of my gastroenterology colleagues didn't know that. So, the study was a population based study of about 54,000 patients, and they looked at people taking a proton pump inhibitor. Those, you know, you might know, it as a little purple pill. So, that's drugs like Prilosec, Nexium, Aciphex, Protonix are a whole host of them on the market, and these drugs are--
Like an antacid, right? An antacid, technically, is a little bit different, shorter acting. The difference with the proton pump inhibitors is that they're long acting, and these drugs have been amongst the most commonly prescribed drugs in the world because they work amazingly well. They're an incredibly efficient class of drugs for doing what they're supposed to do, which is shutting down that proton potassium ATPase, that acid pump in your stomach. So, when you take these drugs, and it takes a couple days to get levels to the sufficient point where you essentially have no stomach acid, and so, for people who suffer from acid reflux, they love these drugs, because you take these drugs, and now you can do all the things you're not supposed to do. You can eat a big heavy meal late at night and you feel fine, but stomach acid is there for a reason. In addition to it being one of the most important components of digestion, we need stomach acid to provide the right acidic milieu for the digestive enzymes to work, so the food can be broken down to provide the right pH, so the nutrients can be assimilated and absorbed, and we've seen with these drugs, what happens when you take 'em long term. I'm not talking about taking this drug for a month or six weeks because you have an ulcer or you have bad reflux. I'm talking about people taking these drugs for several months, and this study, it was looking at people who are taking the drug for four months or more, and some people are on these drugs for decades. So, what the study found is that people taking one of these drugs once a day were twice as likely to have a positive test for COVID, and people taking the drugs twice a day, it was a three to four-fold increased risk, and that's because stomach acid denatures viral protein. So, when you're exposed to a lot of these viruses, the entry point for a lot of us, it can be our respiratory system, it can also be our digestive system, and in fact the ACE2 receptors that bind SARS-CoV-2, we've about 100 times more ACE2 receptors in our GI tract than we have in our lungs, and that's why GI symptoms have been so common with this virus. So, you're exposed to the virus, it gets in through your mouth, you swallow it. If you have adequate levels of stomach acid, the acid denatures a viral protein, and can prevent it from binding to those intestinal epithelial cells and infecting them, and creating that cascade of inflammation, but if you're now on a proton pump inhibitor, and if you've been on one for several months, and you essentially don't have any stomach acid, now you're defenseless, because now your stomach has been converted from a hostile, acidic environment for viruses, to a friendly, alkaline environment, and so, you know, I read that study, and I remembered talking to my literary agent, Howard Yoon, about it, and I was like, "Howard, you know, "people really don't know," and he said, "Well, you know, maybe write an editorial. "You know, maybe an editorial or something," and I was like, "Yeah, maybe I'll do that. "It'll be good to spread the word," and then the microbiome study came out with the faecalibacterium prausnitzii, high levels of that being protective, and they saw the bacteria enterococcus faecalis, high levels of that being negatively predictive in the sense that those are associated with the worst outcome, and I just felt like nobody's talking about host health, and there's lots of people talking about vaccines and other important things, but this is an area that I really know a lot about, with the gut, and it just felt like that part of the public health message was missing and, Rich, in some ways even worse. It felt like if you talked about that, you were somehow saying this other stuff is important.
You're anti other thing. Which I just don't understand, because I'm very pro all the other things that we have in medicine to serve us, but making sure people understand that, and there are people who have to take these drugs, but these drugs are very over-prescribed. There have been studies suggesting that 70%, 80% of people taking them, particularly older people over 65, who are also at risk for other reasons that the majority of the prescriptions are unnecessary, and the interesting thing about PPI's, Rich, is we have seen for decades in the GI world, this increased risk of infection from PPI. So, if you look at something like Clostridium difficile, it's a bacteria that is often prevalent in hospitals, and we think about it as an antibiotic associated diarrhea, because you take antibiotics, you wipe out a lot of your healthy bacteria, and then the C. diff that's lurking, or that you've caught from, you know, a door, or something in the hospital now starts to proliferate, and lo and behold, you have this C. diff colitis, which, you know, kills about 30,000 people a year in the US. So, we've known for a long time that proton pump inhibitors are a major risk factor for C. diff. We know proton pump inhibitors are a major risk factor for campylobacter jejuni, a very common foodborne infection, and other enteric illnesses that affect the GI tract. So, in the GI world, it really shouldn't have been a surprise, but I think the numbers were still pretty astounding that it could increase the risk that much, and, you know, for people on PPIs, there are people who have serious indications, but, again, a lot of the people who are on PPIs can probably get off them, or take a lower dose, or use an antacid, something that you use sporadically. So, an antacid that you take only when you're having active reflux, as opposed to a PPI that you take every day, and, you know, having a really sort of frank conversation with your prescriber about what your indication is for this drug and whether you really need it, and then coming up with a plan for how to taper off, which you will find in the book. Yeah, I mean, there's a difference between somebody who has some kind of chronic acid reflux issue versus the individual who has a terrible diet and is creating that as a result of lifestyle choices, and wants to go on the PPI , so they can continue to perpetuate the bad habit, right? So, it's driving multiple negative outcomes, because it's allowing you to continue to do something that your body is trying to tell you, you shouldn't be doing, right? Your stomach pH is what it is for a reason. It's not just so that it can optimally digest your food. It is this line of defense for these other pathogens, and when you change that pH, obviously, you are weakening your body's ability to do what it's naturally you know there to do. And that's why we see so many manifestations of long-term PPI use in different parts of the body. We see an increased risk for dementia, we see kidney disease, we see an increased fracture risk, because it's affecting and disrupting the delivery of nutrients to all these different parts of the body, but the marketing is so fascinating, and I remember reading this terrific book a long time ago, before I ever wrote a book, called "Our Daily Meds" by Melody Petersen. She's, I believe, a medical journalist maybe for the New York Times, and she described in that book the campaign around acid blocker drugs. So, I think so many people out there believe that they have overproduction of stomach acid. Overproduction of stomach acid is an exceedingly rare condition called Zollinger Ellison syndrome that occurs in about one in a million people in the US. So, that means there maybe 350, close to 400 people in the US who actually have overproduction of stomach acid. For everybody else who has reflux, what they have is inappropriate relaxation of that sphincter, that valve between the esophagus and the stomach that's supposed to shut tight to keep the stomach contents in the stomach. So, we have inappropriate relaxation opening and then the acid comes up, but it's not overproduction, and so, if you start to believe, you know, if the marketing is around overproduction, you think, "Oh, I have too much stomach acid," and the marketing is around stomach acid being bad, then it's an easy step to then say, "Oh, yeah, "let me block my stomach acid, and I'll be better off," but if you really understand that it's that inappropriate opening of the valve, and what opens it inappropriately? Eating late at night, after the stomach is basically shut down and gone to sleep, because it follows the circadian rhythm. So, eating a large meal late at night, overfilling it, the stomach's about the size of your fist, eating food with a high fat, high protein content, like a lot of animal protein, which will slow down emptying of the stomach, caffeine, alcohol, chocolate, all of that stuff. So, when you understand what's going on, and you think, "Okay, I can do some stuff here. "I can eat a little bit earlier, "I can eat a smaller meal, I can eat my big meal earlier, "I can cut down on my dairy, and alcohol, and caffeine." You start to understand how you can effect that, as opposed to doing this incredibly drastic and potentially disastrous thing, which is to completely shut down your acid pump. Sorry to interrupt the flow. We'll be right back with more awesome, but I want to snag a moment to talk to you about the importance of nutrition. The thing is, most people I know actually already know how to eat better and aspire to incorporate more whole plants, more fruits, vegetables, seeds, beans and legumes into their daily routine. Sadly, however, without the kitchen tools and support, very few end up sticking with it. So, because adopting a plant-based diet transformed my life so profoundly, and because I want everybody to experience some version of what I've experienced, we decided to tackle and solve this very common problem. The solution we've devised, I'm proud to say is the Plant Power Meal Planner, our affordable, all-in-one digital platform that sets you up for nutrition excellence by providing access to thousands of highly customizable, super delicious, and easy to prepare plant-based recipes. Everything integrates with automatic grocery delivery and you get access to our amazing team of nutrition coaches seven days a week, and many other features. To learn more, and to sign up, visit meals.richroll.com, and right now, for a limited time, we're offering $10 off an annual membership when you use the promo code RRHEALTH at checkout, this is life changing stuff, people, for just a $1.70 a week, literally the price of a cup of coffee. Again, that's meals.richroll.com, promo code RRHEALTH for $10 off an annual membership. All right, let's get back to the show. Well, continuing on this, I suppose the lane that we're in right now is the impact of pharmaceuticals on gut dysregulation and, in turn, immune system dysfunction. We're all fairly familiar, I think, at this point, with the havoc that antibiotics can wreak on this system. So, I don't know that we need to explore that any further. It's sort of self-evident, but there's some other things here that you talk about in the book that I also didn't fully appreciate, one of them being NSAIDs. Basically, you know, non-steroidal anti-inflammatory drugs, the Motrins and the Advils. Yeah, yeah, so-- Because I've always thought of those being relatively benign. Well, as an athlete, you've probably relied on them a lot too, right? And I'll just tell you my little story about these drugs. As a gastroenterologist, when I used to take calls the hospital, pretty much at least once a month, we would see somebody with near fatal bleeding from taking a nonsteroidal one too many doses, and you don't need a lot, unlike Tylenol, acetaminophen, where to get liver injury from Tylenol, there's a set dose amount that you have to exceed, NSAIDs aren't as forgiving. So, you can take, you know, 800 milligrams of Motrin, which isn't that much, and end up with a huge ulcer. If the area that ulcerated happened to be over a major blood vessel, you can potentially bleed to death, and so, literally at least once a month, we would see somebody with massive, you know, nerve fatal bleeding from an ulcer in the wrong spot that was created by NSAIDs, and so, as a result of that, I'm very wary of taking those drugs. The only time I take 'em, I usually would take 'em at around mile 20 of a marathon. Yeah. (laughs)
I'm a slow, but steady marathoner, but the knees aren't what they used to be. So, usually around mile 20 when it just, you know, feels like bone grading on bone. I would take some, and typically at the end of the race, I would be vomiting and, you know, people are like, "Oh, you really ran hard." I'm like, "No, it's the NSAID." They really affect me, so I get really nauseated, but again, like the PPIs, these drugs work really well. In 2017, I tore my MCL snowboarding. I was out in Utah, couldn't straighten the leg, was in a lot of pain, difficult to fly back, and my husband was like, "Just take some of this. "Like, why are you in pain?" It took away the pain. I mean, it was like magic, and maybe I shouldn't be surprised. I'm a doctor, but I generally don't take these drugs. It was incredible how well this drug worked to take away the pain. So, you can understand for people who have chronic injuries, who are in chronic pain, who have inflammatory conditions, it's understandable how you can take this drug and become dependent on it, but it's really important to understand, what's the price you're paying on the flip side? So, we talked about those ulcers, NSAIDs make tiny little holes in your gut lining that can sometimes be bigger holes that we call erosions, or can be really big holes that we call ulcers. So, that's what those are, and when we do endoscopy, or a technique called a video capsule endoscopy, a little pill cam that you swallow that takes pictures through the GI tract. When we do that in asymptomatic people taking NSAIDs, we see a very high percentage rate. We see in some studies up to 30% of people having these erosions, these little holes in the gut, and so, it's important for people to also understand that it's not just if you're symptomatic. Like me, you're nauseated, you're vomiting because you took too much Motrin, and you feel really sick. You can be asymptomatic and still have this, and again, there are people who need to take these drugs. There are people with severe arthritis, where these drugs are the only thing that keep them functional, so that they can move without pain, but there is definitely a flip side to that, and so, the integrity of the gut lining is really, again, we talked about stomach acid, the gut lining is another one of those really, really important barriers. It is physically, literally a barrier to keep the virus from getting in and penetrating, getting into the bloodstream, traveling to different parts of the body, wreaking havoc in the body, and what we see is that these NSAIDs end up creating breaches, increasing the intestinal permeability, and making you more susceptible. Right, so this is leaky gut. This is essentially--
Or a version of leaky gut. You know, leaky gut is one of those, again, ephemeral, ethereal terms that, you know, people understand a lot of different things by it, but I remind people that what we're talking about when we say leaky gut is an increase in intestinal permeability, and that's a mechanism more than necessarily an actual disease. I see.
It is a mechanism, and other things can do it. You know, intense exercise can increase intestinal permeability temporarily. I mean, it would be an interesting study for you after a really long run or bike ride to check your intestinal permeability before and after. There's some tests you can do and see, but it comes back to normal. So, that's a physiological response, but what we're talking about, and, I think, what's generally understood when people say leaky gut is a persistent increase in the permeability that allows things that normally shouldn't, to go through that gut lining, and enter the body, and be disseminated to different parts of the body, and cause responses. Right, so, in other words, viruses can then leak through that membrane and find their way into your tissues, and create disease. Absolutely. So, that's the relationship between the the gut issue and the immune system issue. That's it.
On that level, yeah. What about birth control pills and other forms of hormone therapy? Yeah, hormonal therapy can affect the balance of gut bacteria. You know, there was a study done, published in "the Journal of Nature" a few years ago, and as you said, we all know about antibiotics, and most of us are pretty familiar with the damage that proton pump inhibitors do, and that change in acid also changes a gradient of gut bacteria. It interrupts that, and so, long-term PPIs can have the same effect, if not worse, than antibiotics on dysbiosis, but this article in nature, looked at about 42 different classes of drugs, and there was a wide variety of drugs that are causing dysbiosis. So, for example, the SSRIs, antidepressants that people use can be associated drugs like Prozac. There's associations with Prozac causing resistant E. coli. I think about all the young women I see with, you know, sort of recurrent urinary tract infections who may be taking fluoxetine, Prozac. So, there are all these drug interactions, and hormonal therapy is another one, and again, I'm not suggesting that these drugs are bad, I am thrilled that we have all of these medications in our arsenal, but I'm a really firm believer and a strong advocate for more judicious use, and for people really understanding the risks, that nothing is free. There is always a flip side with a pharmaceutical intervention, and they need to understand the risk and really personalize that based on what their risk factors are. So, for hormonal therapy, if you are somebody, for example, with a strong family history, if you're a menopausal woman, and you have a strong family history or personal history of breast cancer or endometrial cancer, you might consider that differently versus if you're somebody with a history of heart disease, and what goes into that, but the idea that, you know, every postmenopausal woman should be on hormonal replacement therapy, or every young woman should be on birth control, and, you know, the birth control is one I really struggle with because we know that unwanted pregnancies is something that keeps women, and particularly young women, and young women of color in poverty, and so, birth control has revolutionized the ability of young women to have control over their lives and prevent unwanted pregnancies, and so on, but at the same time, it's important to acknowledge that there is a downside for some people, and that it does potentially have an effect on the microbiome, not so much birth control just on its own, but then if you add in, this is somebody who's taken a lot of antibiotics, this is somebody who's been on steroids, this is somebody who's eaten a highly processed diet. You know, it's one of those factors to take into account as opposed to just, you know, nobody should be on it or everybody should be on it. So, this more personalized approach, and understanding your own medical history and risk stratification, and then putting that in the context of the pharmaceutical is really important. Yeah, beautifully put. I mean, this is certainly not... My intention is not to villainize any medication, but I think it is so important to understand the comprehensive nature of what's going on when you ingest certain things. I think that we have this limited, or, you know, back to this idea of being overly dualistic about things. Like, I'm taking this thing for this single purpose, but there's a cascade of ramifications to that, and not the least of which is how it's impacting our microbiome, and I think it's, you know, I can't say that when I take a medication, I think, "What is this doing in my microbiome?" Like, that's not the first thing-- You don't?
That comes to... Well, I will now. I should, you know. I don't really take medications anyway, unless I'm dealing with something acute, but to understand that we have to think about these things from a holistic perspective that, you know, it's not just about, like, you see the ad for the pharmaceutical on TV and they rapid fire through all the terrible side effects, but I don't know that I've ever heard anyone say, you know, "Might lead to microbiome dysbiosis," or anything like that.
It should, right? Don't you think?
Yeah. I mean, a perfect example of that is cough syrup, and that was one, I have to say the mucus section in the book. Yeah, let's talk about mucus. Geeked out on, because I had been talking about gut bacteria, and dysbiosis, and acid blockers for a long time, but mucus was sort of a new area for me, and a lot of people think of mucus as something that, you know, it comes from your head or your lungs, but the majority of mucus is made in your gut. We make about one and a half liters of mucus a day, and mucus serves some really important purposes. So, it lubricates the gut, obviously, as the products of digestion come through. It provides a protective layer for that razor thin intestinal lining I talked about, and in the stomach, it helps the stomach from being auto digested by all the acid that's being produced. So, mucus is really important, but the role is much more than just a lubricant. It's this cross. Somebody, I forget who it was, described it as a cross between jello and glue, and it's a sticky matrix that ensnares things, and then the celia, the little finger light projections in the lungs, move it all up, and you cough it out or you swallow it, and if you swallow it, and you have stomach acid, then the stomach acid denatures the protein and does its thing. If you suppress mucus, you know, you have a runny nose. When you have a runny nose, it's because your body is producing more mucus to fight something that you're dealing with, whether that's a seasonal allergy or an infection because mucus traps pollen, and irritants, and smoke, and other things too, to expel it from your body. So, you have a runny nose, you take a cough suppressant, or some sort of antihistamine, or something to dry up your mucus, and now one of your main defense, the ability of the mucus to trap and expel, is gone, and so, now it's gonna stick around and maybe get down into your lungs, and what's really incredible, speaking of pharmaceuticals, you look back at things like Mrs. Winslow's Soothing Syrup and the original Bayer formulation for cough syrup. This stuff had heroin and morphine in it, so it really made your kids stop coughing. Maybe they didn't wake up. I mean, it was incredible, and really, for some of these ingredients, it wasn't until the 1970s that some of this stuff was taken out, and so, the American Academy of Pediatrics now recommends that you don't use these cough expectorants or anti-expectorants in kids, but they shouldn't be used in adults either, and again, like, you have a hacking cough, you're trying to get relief, you're, you know, keeping your partner up, but again, it comes at a cost. So, what are some other things that you can do to help with this, as opposed to blocking this really important host defense? And the mucus also provides a layer. You know, in the book I talk about, I don't know anything about football, but I used a football analogy. It's the equivalent of, like, going through 150 football fields to make a touchdown, or something, just for the distance. When you add that mucus layer on top of the lining, it creates this protective layer that the viruses have to wade through to penetrate the gut lining. So, it serves these really important purposes, and then there's also the whole concept of mucins in mucus, which are the proteins in mucus that degrade enzymes. So, just like stomach acid can denature viral protein, mucin's in mucus, an enzyme that can degrade protein, and depending on the composition of your mucins and how healthy they are, you can be the kind of person where, the virus gets in, the mucins in your mucus immediately degrade it, and you're good, versus your mucus isn't that good, and it sticks around, and this has a lot to do with the whole concept of super spreaders. So, we know that for a lot of these viral illnesses, for measles, for Ebola, for SARS-CoV-2, it's often a small group of people who are disseminating the virus widely, and so, if you connect super spreading to mucus, if you happen to get coughed on by somebody who has SARS-CoV-2, but who has really good mucus that has broken down, degraded the virus, you're not gonna get infected, but if you get coughed on by somebody whose mucus is not so hot, they're more likely to spread it to you. So, you have super spreaders and you have super recipients based on, you know, if you have really healthy mucus, you're gonna be protected, versus not. So, the cool thing to me is, like, this is all stuff we can work on. We can hydrate to improve the quality of our mucus. We can not smoke if we're smokers. We can think about the quality of our external environment. There are lots of things that go into it, and a really fascinating aside about mucus is with pregnancy, the cervical mucus, the thickness of it tells us a lot about what's going on. So, that's something that obstetricians have done for years. During labor, they will examine, or sort of leading up to labor, they'll do a manual exam, and they'll tell the thickness, and they can feel it with their hands, and if the mucus is really thin and watery, they know that that person is at risk for preterm infection because the mucus isn't thick enough to prevent pathogens from getting in, and they may do something differently. So, you know, it's mucus not just in the GI tract, but also cervical mucus. We can tell different stages of ovulation based on what the mucus feels like, and fertility. It's really cool stuff.
That's super fascinating. Yeah, I mean, I didn't realize the diversity of mucus. I always understood it to be a protective, you know, system in our body that can neutralize diseases, but it's also something that we've kind of been conditioned to fear because disease spreads through droplets, and on the subject of super spreaders, you're in an enclosed environment with a lot of people, and somebody sneezes or coughs, or, you know, mucus is shared communally. Like, that's something to be terrified about, right? But to the extent that some people's mucus is benign or safe versus the person who has the subpar mucus that can, in turn, be an accelerant to the spread of disease is fascinating. So, first of all, I mean, the obvious question is, like, how do you know if your mucus is doing its job? And what are the things that you can do to ensure that your, you know, mucus is tip-top? I mean, hydration, is it like, you know, humidifying your room, diet?
Yeah, and diet. Diet plays a huge role, and the humidifying may help if you're congested. I think the thing about, you know, you mentioned about being terrified of mucus, other people's mucus isn't as cool as your own mucus. It's kind of like other people's stool. I don't really want that.
My stool is good, but-- That's fine, I'm sure it's good. You know, I don't need it. There are lots of tips. You know, one of the things that my team at Avery who I've been with them for all the books from, they took a chance on me in 2013 with "Gutbliss," all the way through, is it really encouraged me to provide more actionable information, because I'm like, "Oh, this is great. "I'm gonna tell people all about this," and, like, that's good to know, but what can I do? What am I supposed to do? And so, with this, it went from being like a little side thing with "Gutbliss: Microbiome Solution." I had a bigger plan with this one. It's a third of the book. Page count wise, it might even be closer to a half, and to really, you know, think deeply about, so, if we think about fever, something we haven't gotten into yet, what are the guidelines? And really pulling those guidelines about when to treat a fever, when not, what else can you do? Medication section, if you're not taking an NSAID, what else could you take? And here are some questions to ask your your doctor. What about every other day dosing? What about these kinds of NSAIDs that are not as disruptive to the GI tract? So, really trying to feel a little more prescriptive for people, as opposed to just, you know, "Don't do this." Right. Well, let's talk about fever and heat, because this is another thing. It's like, "Oh, I have an ache." "I'll take an Advil." "Oh, you know, I'm feeling phlegmy. "I'll take a cough suppressant." These are all very, you know, knee jerk, common reactions to ailments that we've all experienced, and on that note, the idea that, when you have a fever, "Oh, we need to bring the fever down," like, this is not good, right? So, walk us through the protective mechanism of the fever and what it's doing to us, and when it is appropriate to try to lower it, and when we should just let it run its course. And I'll tell you, fever's one of those things that was good then bad, and may be getting good again. So, this idea of, you know, you think about different cultures and things like sweat lodges, and saunas, et cetera. That's all thermal therapy, that's all heat therapy, and Hippocrates, I mean, everybody's familiar with, all disease begins in the gut, but Hippocrates also famously said, "Give me a fever and I can cure any illness," and I think it was in 1927, an Austrian physician won the Nobel Prize for heat therapy that was being used to treat neurosyphilis successfully. I mean, of course, we have drugs now that are more effective. So, heat therapy and this idea of fever as being therapeutic is not something new. We're seeing now thermal therapy in cancer, finding that using heat to treat cancer cells, to kill them, is effective. Polio virus replicates 250 times faster at normal body temperature compared to with a fever. So, fever is a really important defense your body has of slowing down, if not halting, viral replication, and what's the first thing we do when we have a virus and a fever? Is we reach for an antipyretic, something to stop the fever. So, understanding that fever is a body's sign that there's something going on, and also our body's therapeutic response to try and handle that thing, whatever it is, that's going on. So, just the replication rates, and so, in the book I do talk about when it's okay to take an antipyretic, or maybe if you can even wait a little bit, and then take it. Allow your body time to try and get its anti-viral fever virus, you know, slowing down replication processes going, but there's really interesting data too. There's some mice studies. If we look particularly at elderly people, a lot of the morbidity and mortality around COVID with elderly people is this condition ARDS, acute respiratory distress syndrome, which is essentially lung failure, and studies in mice show, that at high heat for a few hours, we don't see the respiratory cells dying the same way, and then you think about the fact that elderly people often are not able to mount a high febrile response. Kids can get their temperature up to 105, 106, but older people not so much, and so, they're looking experimentally now at whether thermal therapy might be a treatment for ARDS. I mean, this hasn't gone into the human stage yet, but they've seen it in mice for slowing down the death of the respiratory cells, and then again, we've seen similar thermal therapy happening in the cancer world. So, again, we have to be thoughtful about this and we have to understand the process. What is our body trying to do? And make sure that we're not sabotaging that process in our efforts to feel better, and there are plenty of things you can do to feel better when you have a fever, that can do that and make you more comfortable without sabotaging that process, and also understanding for our kids, you know, it's not just a temperature, it's, what else is happening with your kid? Is your kid listless, not eating, not making eye contact, especially with babies, that's a more worrisome sign. The kid might have a fever of 104, but it's running around, eating, playing, laughing. That's a whole different matter. So, what else do you look at. and how do you, you know, how do you make this evaluation? Obviously, this should be done in concert with people's healthcare practitioner, but giving people some basic information about that and some questions to ask. Yeah, well, obviously, if you have an elevated body temperature, and that's slowing replication rates of the acute viral infection that you're trying to combat, you want to allow that to take place, but I would presume that there are other physiological systems that get disrupted by an elevated body temperature, and at some point when that threshold, that temperature threshold exceeds a certain set level, it becomes problematic, and you do want to bring it down. That's right, and again, it's not just the number, it's what else is going on, but I'll tell you, and that's why it's important to have that done in a natural medical setting, and not just rely on, you know, what I'm putting out in my book. A couple other things in terms of the gut fever connection. So, when you have a fever, it slows down viral replication, it also recruits additional immune cells for the immune response, and can enhance production of certain anti-viral cytokines, and interestingly, in the gut, it helps to tighten up those junctions. So, those connections between cells, we talked about intestinal permeability, the tight junctions, when you have a fever, the tight junctions realize, "Oh, we're battling something here. "We need to tighten up our battalions, our forces here," and the junctions become tighter and the gut membrane becomes less permeable to whatever virus, bacteria, et cetera, you're fighting. So, it's just fascinating how your immune system, your gut, all the different things that are going on when you have a fever. Super interesting. Did you look at any of the research or science that's coming out on sauna therapy, not in the context of combating an infection, but just as a daily practice in terms of what it's doing to us, benefits, negatives? I'll tell you, I haven't, Rich, but I'm a huge sauna fan, anything hot. I do heated vinyasa flow yoga, I love saunas. I feel like heat and, you know, you could hearken back to Ayurveda, and talk about pitt-vata and maybe do some analysis there, but it certainly feels good in my body. Give me a little update. Well, I just think--
What have you found? I mean, I'm certainly no expert on this, but I know there's some indications that it perhaps might be a longevity extender, and certainly, as an athlete, in terms of recovery, and all these other kind of things, there seems to be some interesting signs coming out to support that, but then the next thing I wanted to ask you is, you know, cold exposure, like ice baths, because this is all the thing now, and I've been playing around with, like, the sauna, and the ice bath, and going back and forth. Is there anything that you learned about cold therapy? Yeah, you know, these extremes, and this is really connected to the idea of stress and really important here to distinguish between acute stress and chronic stress. So, these acute stressors, cold, fasting, running long distances, heat, tend to all be moving us in the right direction, I mean, depending on how it's done, and what your baseline is, but these are all things that have been associated with longevity, and with, you know, improving health in different studies, again, depending on the context. With acute stress, you are actually recruiting additional immune cells and you are strengthening that response, but it's the chronic stress. So, you want that fight or flight for short, brief periods of time, and you want it to be able to, you know, escape the lion, or the snake, or whatever it is that's about to attack you, but you don't want that revved up immune system over long periods of time, because then that becomes a problem, and that becomes a threat to your health. So, it'd be really interesting to look, and I don't know the intermittent exposure to cold therapy and cryotherapy versus a sustained cold response, whether that moves you from a realm of acute stress to chronic stress, and how that works, but certainly little touches of that are... I mean, I could tell you that it's definitely a mood elevator, and it's certainly an anti-inflammatory. Like, it's helpful in recovering from exercise induced stress, and I just feel better in my body. Like, I know it's a good thing. Like, I'm interested in the science that supports that. Well, there's definitely a lot of it out there. I'm from Jamaica originally, as you know, and we would sum it up by saying, a little separation is a good thing. (laughing)
A little separation. I think that's the title of this podcast. You just coined it, what I'm gonna title it. (upbeat music) Prophets walk among us. As a writer and podcaster for nearly 10 years, I've become more convinced than ever that our world is populated by scores of beautiful and brilliant people who have amazing stories to share, those that we don't know who can teach us something new, and leave us all the better for the experience of their sharing, and so, I've dedicated my career to tracking down the most compelling prophets on the planet, going deep with each of them on my podcast to elucidate the best of what they have to offer and to sharing the insights gleaned for the benefit of all, but the podcast is not the only medium by which to share their stories, which is why I'm proud to announce the release of my new book "Voicing Change: Volume II". More than mere words on paper, "Voicing Change" is a physical manifestation of the magic, inspiration, and timeless wisdom that transpires each week on the Rich Roll podcast. The first edition of "Voicing Change" was a beautifully rendered book worthy of display on any coffee table, and volume two follows in that tradition by showcasing even more of my favorite conversations in an elegant publication, replete with interview excerpts, essays, and stunning photography, making for an exquisite companion to the first volume, or a satisfying standalone work. Picking up this book allows you to revisit the wisdom of your favorite everyday prophets, and physically interact with the life changing ideas contained within. "Voicing Change: Volume II," available now while supplies last for a limited time. Order your copy today only at richroll.com. Let's talk a little bit about food and diet. This is something we've explored extensively also in past episodes, so I don't want to linger too long here. We all know we need to increase the amount of fiber in our diet. There's this rule of thumb, 30 different plants a week, basically, but there were some other things in your book that were a little bit new to me, not the least of which was this emphasis on, not just fiber, but short chain fatty acids, specifically inulin. So, talk a little bit about that. Yeah, so, there are very few bad plants, of what's edible, poisonous stuff isn't good, and I'm not a huge fan of creating these hierarchies, white potato, bad, sweet potato, good, et cetera. Most of us, I would add to Michael Pollan's fantastic book, "In Defense of Food," you know, he has that little thing on the cover that says, "Eat food, not too much, mostly plants," I would add to that, eat more vegetables. The numbers are just astounding. Less than 5% of Americans are getting the recommended grains, and greens, et cetera. So, we all need more vegetables. Even many of my completely plant-based patients who are eating a lot of process plants need to eat more vegetables, but there are some in particular that really have a pronounced effect on the levels of short chain fatty acids, and so, when you look at something like inulin that you can get from rolled oats, and from onion, and garlic, and leaks, et cetera, what we find is that kind of fiber, it's sort of that stringy fiber, hard fiber is the preferred food of bacteria like the faecalibacterium prausnitzii, in terms of the fermentation process, creating short chain fatty acids like butyrate, propionic, et cetera, and these short chain fatty acids help to regulate the immune system. So, they help to prevent that overblown response, but they also act locally on the immune system. So, it's not just sort of acting in a more general managerial way, but on the local immune response. So, for example, they can down regulate the number of viral receptors in tissue, sufficient levels of short chain fatty acid. So, we've known for a long time, there've been some landmark studies, Paolo Leonetti's study from, gosh, that study must have been early 2000, maybe, no, maybe 2012 or so, from about 10 years ago where he looked at kids in Burkina Faso and compared them to kids from Florence, Italy, and the kids eating the Florentine diet were eating kind of a standard American diet. Because it had become Western. It was no longer a-- It's not a Mediterranean diet anymore. Yeah, and the baby, the groups of of babies were similar at birth. These were for vaginally born, breast fed babies, but once they sort of graduated to table food, everything changed, and the kids in Burkina Faso were eating essentially almost 100% plant-based diet, except for I think they were eating some termites in the rainy season, and a free range chicken here and there, versus the kids in in Florence were eating a lot of animal protein, fat, sugar, et cetera. The microbiomes were vastly different, and one of the biggest differences was the levels of short chain fatty acids. The kids from Burkina Faso had more than double the levels of short chain fatty acids, and the fascinating thing about this study, Rich, is that neither group of kids were sick. We're talking about infants, these are healthy infants, but you could already see the foundation for disease, for susceptibility to viral illness being laid down in the microbiome, and again, to your point, host health matters, and it matters early on too. I mean, of course, there are other fantastic studies that show you can change this stuff within a short period of time, but, you know, this foundation that we're building is really important, and I really focus with my patients on what you're missing, more than what you're eating. You're eating pizza, you know, we can deal with that, but you're missing the kind of fiber, that fibrous fiber that is going to lead to production of short chain fatty acids, that is gonna keep you healthy, and so, really focusing on adding, and it can literally be adding in a stock of celery. And those short chain fatty acids really help to patch any of these holes that are leading to leaky gut. Absolutely. That is sort of like the cure to that, or the fix. It's strongly correlated with more normal intestinal permeability, yep. So, what say you to the carnivore diet enthusiast who is telling you that all this nonsense about fiber is overblown, and I've been eating nothing but steak for the last year, and I feel fantastic. Well, you know, I think it's important for people to understand the concept of statistics, and we were talking about this earlier. Like, we all know people who've smoked two packs of Marlboros for 90 years, and are fine, but does that mean that cigarettes do not increase your risk for lung cancer? Of course not. So, you know, we have to rely on the population based data that we have, which is very robust, and we know that fiber is a main ingredient for creating a healthy microbiome, fiber in fermented food. That's really not up for debate. Now does it mean that there's not room for animal protein on the plate? No, it doesn't necessarily mean that. There are other reasons to avoid animal protein. There environmental reasons, and ethical reasons, et cetera, but from a medical lens, it's making sure that there's sufficient amounts of digestible plant fiber on the plate. That is really the most important element of that, and then the issue about whether you're going to eat meat or not, again, that's a more personalized, individualized issue, and lots of other factors go into that, but there's no debate about the fiber, and it doesn't mean that... Of course you could be a carnivore your whole life and somehow have managed to be fine, but you're in n equal one number, that does not a scientific study make. Right, so, the low hanging fruit in terms of things to avoid would include artificial sweeteners, sugar, fatty foods, alcohol, processed foods, we're all, you know, this is all, like, common sense stuff, but I loved the example that you gave of your patient called Alicia, because I feel like that really illustrated the interplay between all of these things, and how challenging and difficult it can be to diagnose somebody who's coming in to you with, you know, some sense of something being awry, and the process of trying to figure out how to untangle that knot. Can you tell that story? Yes. She was the one who was obsessed about fungal organisms, and I see this a lot in my practice, because, again, there's all this hype around different things. It's an overgrowth of fungal organisms, and you have candida overgrowth, and that's what's causing all your problems, and it's really balance. So, we need yeast in our microbiome. Yeast play a really critical role in part of the digestive process, but we don't want too much yeast, and so, when you kill off a lot of the healthy bacteria with an antibiotic, you leave more room in there, and you can get overgrowth of fungal organisms, but she had been eating a super restrictive diet, essentially no carbohydrates, and she was eating a occasional little bit of vegetable, green vegetable, no fruit, no grains, tons of meat. She'd taken these really potent antifungals, and I was really concerned about her liver and reminding her that the food for our healthy gut bacteria are carbohydrates. It's not meat. Right, but there's this huge fear of carbohydrates. Yeah, and that carbohydrates make you fat, and you see the studies coming out all the time showing that a primarily plant-based diet, whole foods, plant-based diet is not just for overall health, not just for resiliency to viruses, but also for weight, but people somehow have gotten so stuck on this idea that carbohydrates are bad. Carbohydrates are incredibly important fuel for the gut, not just to grow a good gut garden in terms of gut flora, but also for providing bulk in the stool, so that things can move along, and I see these patients coming in on these ketogenic diets, incredibly constipated. Yeah, that's a common thing. Let's talk about sleep. Some of the statistics in the sleep section of the book are, like, mind blowing. Like, what happens in our gut when we're sleep deprived? The risk of viral infection skyrockets 88%. Is that true?
Crazy. I have to say, when I turned in the first draft of this book, the sleep chapter was 60 pages, and the folks at Avery were like, "Matthew Walker wrote that book." Yeah, you're not Matthew Walker. Yeah, "Sean Stevenson wrote that book." There are really good sleep books out there, but it was so fascinating, Rich, and, you know, when you think about it, you can go without food a week, and you will be hangry, but you can go without food for a week. You can go without water for a week, and your kidneys will start to shut down, but you'll rehydrate, and you'll probably be okay. If you go without sleep for a week, you will be very close to dead. Your testosterone levels will drop, your risk for cardiac disease will triple, all kinds of things will go wrong in your body without sleep. So, really, the elixir, sleep is really essential, and the sleep-gut connection is something that is also really profound. Serotonin, which many people know as a feelgood hormone is made primarily in our gut, about somewhere between 70% and 90%, depending on which study you read, of serotonin is produced in our gut, primarily by our gut bacteria. Well, serotonin is a precursor to melatonin, the sleep hormone, and so, if your gut bacteria are off, and you have a messed up gut, and your serotonin production is down, which is a real thing we see, and that's why there's such a correlation between gut disorders, and psychiatric disorders and mental health. So, if your serotonin is off, your melatonin is gonna be off, and your sleep is gonna be affected, and vice versa. If you're not sleeping well, that's also gonna throw off what's going on with your gut bacteria. So, one of the things I see, for example, is with my college student patients, they're always sick around exams when they're not sleeping, and for a lot of my patients with Crohn's disease and ulcerative colitis, with complex autoimmune diseases, they'll tell me that sleep is the thing that totally, if the sleep is off, they'll have a flare, more than anything else, more than their diet, more than stress, more than anything else, is really the sleep. Less than four hours of sleep correlates to a 7% drop in critical, no, I think it was 70% drop in critical immune cells the next day. That's absolutely right.
So, this happens very quickly. It's the reason why I'm not taking the red eye back tomorrow. I'm done tomorrow afternoon, too late to catch the 4:45 to get back to DC, but in time for the red eye, but I know I won't sleep, and I'm like, "No, I'll take the 7:55 in the morning. "I am not risking that." There's crazy data about sleep and vaccines too. So, if you are sleep deprived before your vaccine, the effectiveness is significantly reduced, and our daughter who's a rower, when she was getting her first vaccine, it was during the regatta season and she had to get up at like 4:00 A.M., or something, I forget where we were in Philly, or I was going somewhere the next day, and I'm like, "Nope, we've got to reschedule that. "There's no way you're getting a vaccine "after, you know, four and a half hours sleep," and so, there's really clear data, not just in older people, but in everyone, that being sleep deprived in the 48 hours before you get a vaccine can lead to a decrease in effectiveness, in some studies by as much as 30%, and that's not just for the COVID vaccine, that's also for hepatitis vaccines, for flu shots, et cetera, and, you know, it's just not something that I think is even in our awareness, this idea that it would matter. We just think, you get the vaccine, it works, but this is one of these factors, and when you look at some of the statistics in the book that you just read, the drop in immune function when you're sleep deprived, you really start to see how it's all connected. Yeah, it's unbelievable. The other one that hit me really hard was every hour that you sleep is associated with 12%, a 12% reduction in the odds of becoming infected by viral infection. I mean, infected means, how are you defining that? Because exposure--
Meaning ill, becoming ill. Becoming ill, okay.
Yeah, becoming ill, but, you know, I think we can all think about times in our life when we've been, you know, for me it was every year before a big GI conference, Digestive Disease Week, which happens in May, and typically, especially when I was still full-time at the hospital at Georgetown, and so, I'd be working on five or six different presentations, and, you know, it's like, you know this stuff is coming six months in advance, but it's still last minute. You're getting slides together, and you're, you know, finishing stuff up, and not sleeping, and invariably, I'd get sick, and you know, as I said, I see it with my college students who have chronic autoimmune diseases. You see it. You're run down, and you're more likely to get sick, and we know that in the back of our minds intellectually, but when you're run down, you're tired, you're not sleeping well, you're more likely to get sick, but I think we're not aware how profound that impact is, and I think, Matthew Walker, when he was on, talked about this incredible global study with daylight savings time, and how we see this tremendous increase, I think, up to a 25%, 24%, 25% increase in heart attacks the day after we all lose an hour of sleep, and then a drop, not as dramatic, but significant. And then when you think about residents, med school residents working these insane shifts in hospitals where they become more susceptible to disease and infection, then, of course, they're gonna be more likely to shed and spread it when they're doing their rounds. Go into any hospital physician's lounge, and look at what's in there. It's soda, and donuts, and ham sandwiches. Why can't we solve that problem? And, you know, Neil Bernard and his wonderful group, Physicians Committee for Responsible Medicine are doing a petition now. They've been helping them with the folks at Georgetown to remove known carcinogens from the hospital meal tray. So, sausage, bacon, I mean, you could argue about whether you are gonna serve animal protein or not in hospitals, but you cannot make an argument for why you would be serving sausage and bacon to sick people in the hospital. My dad had a cardiac catheterization about five years ago, had an acute event playing tennis, and went in, and had state-of-the-art care at Washington Hospital Center, incredible cardiac services, and they went right in, aborted the heart attack, fantastic. I was in New Haven at a college reunion. I rushed back, he's sitting there, he's lying in the bed, there's a hamburger on his plate. This is what they're serving him after an acute cardiac event, you know, out of the cath lab, recovered.
That's total insanity. Insanity. Why is it so difficult to solve this problem? Like, where's the missing link in resolving this equation? I think it's--
Is it the money? Is it government contracts? It's disassociation between acute treatment of illness and prevention of illness, and what we have seen, Rich, is that the medical community has not done a good job on the prevention side. I think we can all agree. We're really good with the acute side. I am thrilled that Washington Hospital Center was available, and 10 minutes away, and they did a fantastic job with my dad, and I do credit them for that, them and his cardiologist Jack Flyer, for why he's alive at 87, and doing well, and eating lots of lentils, but the prevention side, we don't do, and when you think about it, having people be ill keeps these organizations in business. Now, I don't think that they're thinking about it that way. They're not like, "Oh, we hope he goes out "and has another cardiac event." Not at all. It's just that it's not on their radar. They're in the business of the acute care and interventions, and they're not in the business of prevention, and we've seen these other industries that have flourished, health coaches and other people who are really focused on that, on the diet and lifestyle, and I think it's wonderful, and it has arisen out of a great need, which is a fact that we've neglected it, and the medical visit is fast, hospital-based medicine, so you don't have a long time. So, we needed to have other resources for people, other places for people to go to to learn about that. Yeah, you kind of raise the conspiracy flag of, you know, the system is set up to keep sick people sick, because that's where the money is getting made. I think what gets confused in that conversation is this idea of mustache twirling, you know, executives sitting around a table like this, conspiring to, you know, extract money from the woe-begotten consumer. It's not that. It's just that there is a certain system in place that's very profitable, and when that is the case, there are many parties that are invested in maintaining the integrity of that system, and it becomes more and more difficult to make changes, but to your point, the explosion of functional integrative medicine practitioners is very heartwarming, and they are serving this need, and I think it's cool to see that blossom. They found a way to make it economically viable. I think that was the big impediment, right? Like, how are you gonna be able to make a living doing this when the system is set up such that you need to see x many patients a day for 15 minutes each, because of the way insurance companies have, you know, created the reimbursement schedule. And it's not just a, you know, at the practitioner level, in terms of physician level, but it's really people like health coaches who are much more grassroots, who can do the hand holding, and the explaining, and the walking through and, you know, really have that frequent interaction because, you know, gastroenterologists are really good at doing colonoscopies and endoscopes, but most gastroenterology programs even today don't have formal training in nutrition, really significant training in terms of, you know, explaining to somebody, what's the difference between gluten intolerance, and a wheat allergy, and celiac disease? And even when we know it, and I think most gastroenterologists do know that, but do we have 45 minutes to sit down and explain the difference to somebody who's just been diagnosed with celiac disease versus somebody who is just gluten intolerant, I shouldn't say, just, but somebody who's gluten intolerant, that these are very separate conditions and they require very different approaches, and so, you know, I think of it as these, you know, grassroots community based folks who can really do that heavy lifting. I would like to see more disease specific training for some of the health coaches. A lot of 'em have great empathy, but maybe not as much specific training in the different areas, and I think when we get that... So, we have like a whole army of, you know, diabetes educators, or dysbiosis educators, people who help people understand gallbladder disease and what to do so you can hold onto your gallbladder if you have gallstones, and not have to have it removed. So, we start to see more of that disease specific training with health coaches. I think we'll really start to move the needle. Yeah, and the follow up and the accountability that's so critical to actually getting somebody on a better path. And the working with the medical community, so that it's not either, or, but you are working with a health coach, health coaches attached to medical practices. Like, the gastroenterologist might diagnose somebody with celiac disease or gallstones, and then they refer them to the health coach, and then the health coach does all that work with the diet and lifestyle, the sleep, the stress, the food, and then there's more cross pollination between the two. So, that's something that I would love to see, and I think we're moving towards it because I think consumers are demanding it. Let's talk about weight, specifically, obesity. I think we're all aware that obesity was the biggest comorbidity factor that was driving severe COVID cases. Some of the statistics in your book, you know, are pretty heavy. 78% of patients hospitalized for COVID were obese. 113%, were 113% more likely to be hospitalized for COVID if you were obese, but the interesting thing to me that I'd never really considered is the extent to which obesity becomes a public health crisis. So, explain that, because I've never really pondered that. I tell you that was pretty shocking to me too. So, if you think about obesity, what the risk is to the individual, we know with something like COVID, so you're gonna have trouble ventilating the lungs, expanding the lungs, because of the adiposity, because of the pressure on the chest if you're obese, so you have issues with ventilation, you're going to have issues with potential complications like clotting, because increased weight in the setting of obesity is associated with increased clotting factors and other inflammatory things floating around in the bloodstream, and you're going to have an altered immune response, because adipose tissue, fatty tissue is itself immunologically active in a negative way, and can lead to an overblown immune response. Those are all things that can affect the individual, but in terms of what it means for society, having obesity is also associated with prolonged viral shedding. We've seen that for influenza, we've seen it for SARS-CoV-2, and many other viruses. You shed the virus longer. What that means if you shed the virus longer is, that there's more opportunity potentially to infect somebody, and there's also more opportunity for the virus to become more virulent during that process, and so, from a public health point of view, if you have a population with a large percentage of people in it who have obesity, you are potentially going to end up with a more virulent viral outbreak over time. Yeah, the shedding with influenza was 42% longer for people who were obese. So, it's not a small margin. Yeah, that's right, and that was stunning to me also, and it also makes me think about, you know, we saw a lot of collective concern, and people coming together in goodwill during this pandemic, particularly early on, and so, realizing that this is a problem that we all share, that we all have a responsibility to figure out how we can help, whether it's individually or from a policy level, make sure that people who struggle with obesity have access to better food, safe places to exercise, stress reduction, all the different things that contribute to it, because, A, it's the right thing to do, and B, because it has a ripple effect on the whole society. Of all the comorbidities, why is obesity such a powerful one when it comes to susceptibility to viral infection? I think, Richard, it's because of all the different elements it effects. So, there's a mechanical, anatomical issue with the lungs, and when you can't expand your lungs, you end up having collapsed alveoli in the lungs, and the bacteria there start to produce, and you end up with secondary infection, bacterial super infection. So, having a bacterial pneumonia on top of COVID can be really deadly. So, with obesity, there are mechanical factors, there are physiological factors, there are hormonal factors, there are endocrine factors, there are immune factors, so it's a condition that affects, you know, every aspect of our body's physiology, and I think that, unlike heart disease, where, okay, heart disease primarily affects your heart, it may affect your circulation, diabetes is primarily an endocrine disease, but with obesity and, of course, our risk for all of these things, heart disease, cardiometabolic disease, cancer, et cetera, are increased. I mean, obesity doesn't live in a vacuum. It's usually associated with some other battery of, you know... Absolutely.
Poor health outcomes. And it's also very strongly correlated with changes in the microbiome. We can look at microbial sample and we can predict with pretty good accuracy whether this person has obesity or not based on the complemented bacteria. So, it's strongly associated, but I can't say that's the factor. It's the fact that it is, you know, effecting so many different--
And you mentioned something about adipose tissue specifically. Sorry, I interrupted you, I didn't mean to.
No, no worries. Something about the adipose tissue specifically that that has a negative impact on immune response. Yes, the adipose tissue can itself release more immune cells more than you need. This whole concept of overshooting and cytokine storm. So, that's another potential complication there for people who have obesity. Well, let's talk about getting outdoors, exposure to nature. Bathing in the biome, right? This is a big part of taking care of our gut health, is our exposure to our natural environments, and another statistic that jumped out to me from the book on this was what they discovered in the wake of the 1918 Spanish flu epidemic. That was fascinating. So, you know, we look back 100 years, more than 100 years now, and we found that this concept of the open air factor, and it's defined as a germicidal constituent in open air, that it's basically, factors in open air, many of which we're not sure what they are, that are lethal to viruses and certain pathogenic bacteria, and in the the Spanish flu epidemic, what they found is that people who recovered outside had a much lower mortality, and when we look at it in the military setting, officers were often given a hospital bed because they were officers, and the enlisted men were put in cots outside the hospital when the hospitals were overflowing. Well, the mortality was very different. In some of those studies, the officers recuperating inside had up to a 40% mortality and the enlisted soldiers on the cots outside had a 13% mortality. That's a massive difference. That's a massive difference, and so, we see that, if you look at the impact of something like forest bathing, and the exact Japanese term escapes me at the moment. It's something shinrin, oh, I'll mess it up, but we know from a couple different studies that that lowers blood pressure, it decreases risk for heart disease, it increases feelings of wellbeing, it decreases feelings of stress, et cetera, but it turns out from an immune point of view, it also does some pretty amazing things too. So, this open air factor is different from just sunlight and Vitamin D. Sunlight and Vitamin D is a thing for sure, but it's open air, and so, if you can't get outside and stroll in the woods, you can open your car window. I'm going like this, but it's more like this. Pressing the button, rolling it down. Nobody's car window opens out anymore. You can open a car window, you can open a door, you can literally sit on a window ledge, and it's been striking even in my own life how much time I spent inside during the pandemic. We're really lucky to live right on the edge of Rock Creek Park. We moved since you were there last. Literally, the trailhead is right outside our door, so it's really easy for us to get outside, but especially with writing this book. I mean, I was sitting eight hours at a stretch sometimes on my computer looking out through the glass at the woods, and, you know, I tell you, like, getting outside, you feel it, you feel better. It just has this, you know, exercising outside, I mean, I love the gym I go to, I enjoy hopping on my Peloton bike, but there's something about being outside in the woods in nature that feels very different for mood, everything else, and it turns out that that effect is very real, this germicidal constituent, and it can be tricky. It was tricky in the beginning of the pandemic when everybody was being told to stay inside, and isolate, and all of that, but we were lucky in Washington to have these beautiful outdoor spaces, and you're lucky here too in California, but that's something that people really should think about incorporating, is this time outside in nature, and ideally getting a little dirty, exposure to soil microbes. Yeah, it's not just the air and the sunlight, it's the greater microbiome of our external environments and the diversity of, you know, whatever is growing in the air that we're breathing, that is serving our gut health. I had a funny story. I had COVID in January, but I had read that study a year before, and I had told my family, "If I get COVID, you need to put a little cot "outside on the deck for me, "and that's where I'm gonna isolate," and just bring my food out there, and that's where I want to recover. I had COVID in January, a couple days after New Year's. That's not ideal. The day before a huge snowstorm, and I'm somebody who, you know, as I said, I like heat, I like it hot. So, my family was like, "Yeah, about that cot." I was like, "Yeah," I mean, it turns out I had it and my husband had it the next day. My daughters were all able to isolate together, which was marvelous, but what I did do, beginning with that next day with a huge snowstorm, was I was out. I would bundle up, double mask, and I would hit the road late at night, and I was, you know, trying to do as many miles as I could, breathing, because one of the things I also experienced was, lying on my back, I could feel alveoli tissue collapsing. It was like, I can't lie on my back all day like this in the bed. I could feel it, and starting to get a little chest pain. So, I got an incentive spirometer, one of those things they use in the hospital after you've had surgery, where you do the deep breaths. So, I was doing my incentive spirometer. I was going out and walking. I mean, I wasn't out trying to run a marathon, but really doing as much as I felt able to expand the lungs, and some of those things, those basic things, you know, we put people in the hospital on their backs, bad things happen. So, some of these things that people can think about, you know, if you're able, and again, not to overdo it, but do what you can manage, which will depend on your baseline of getting outside, fresh air, breathing deeply, all of these things. They're important. From a policy perspective, I presume that the powers that be at the CDC, et cetera, had some awareness of this 1918 Spanish flu epidemic, and the difference between recuperating outside versus inside. Why and how does that not get translated into public messaging about how to best take care of ourselves? We were told to stay inside. I live out in the middle of nowhere, and habitually run trails where, if I'm out for a couple hours, maybe I see two people, and there was yellow tape, like, on these crazy trails. On the playgrounds. It was basically illegal to go out and do exactly this thing that has been proven to be beneficial, as opposed to harmful as we were told. The lack of public health messaging around this is really astounding. If you look at something like antibiotics, we clearly, if you take rotavirus infection, rotavirus viral infection kills about half a million children a year around the world, serious diarrheal illness. We know that if you take certain proteins from bacteria and inject it into mice with rotavirus, it halts the diarrhea, and basically they're good, and we know that kids who have been on an antibiotic immediately before getting a rotavirus viral infection, and, by the way, antibiotic as you know, has no activity against a viral infection, but they still sometimes, "Oh, diarrhea, they're sick," they get this antibiotic. We know that they're five times more likely to have a bad outcome from rotavirus. We know the same thing for COVID and other viral illnesses. Gut bacteria are essential. They're an essential part of fighting these viral illnesses, not just with modulating the immune system, but by actually releasing proteins that help by competing for binding sites with the viruses, all these different things. No messaging, nothing saying, don't take an antibiotic if you have a viral infection, and not just no messaging. We still see physicians, hospitals, other healthcare practitioners saying, "Well, you have COVID, "but just in case," and granted, they're definitely--
Prescribing antibiotics. You have bacterial-- I thought we'd kind of gotten past that. It's been astounding, Rich, and, of course, you have to pull out from that the people who either have a secondary bacterial super infection or are at risk, but the majority of people who were getting slapped on antibiotics had none of that and actually worsening this person's likely prognosis with antibiotics. So, things like getting outside things like, you know, avoiding unnecessary antibiotics, things like, don't suppress your cough or fever. I mean, these basic things, and it's puzzling to me, and I don't know if maybe the feeling is, if we focus on these things, it will seem like we're detracting from those, but that that doesn't really make sense. Yeah, I feel like, you know, they should have trusted us a little bit more to understand that, yes, we need both. We need to take care of ourselves to put ourselves in the best position to, you know, basically fend off this illness that we're almost undoubtedly gonna come into contact with, and understanding that not everybody is equal and there are certain things that we can do to put us in a better position, you know, if and when that occurs, and it's not an if, it's a when, but I don't know, maybe they felt like that would detract from the other messaging, but I think we're gonna be doing a forensic excavation of what went wrong and what went right for many years to come, and, because we will inevitably face another pandemic, my hope is that we'll have our ducks in a row a little bit better for next time. Well, if you look at the statistics, there've been over 30 different viruses in the last 50 years for which there is no cure or real treatment. So, things like hepatitis C, HIV, Ebola, SARS-CoV-2, a study from Duke in 2021 looked at the statistical likelihood of a pandemic of the proportions we've seen with COVID happening, and calculated that at 2% per year, which means for somebody born in 2000, that's a 40% likelihood by 2020 that this would've happened, but, yet, we still seem very surprised, you know, and again, there's precedent for all of this, and a lot of the things that we did seem that they weren't super innovative, and I think it's really easy to look back with a retrospective scope and say, "We didn't do this right, we didn't do that right," and there was clearly a lot of panic. I feel like we're in a less panicked mode right now and we're able to be more thoughtful, thoughtful about maybe stratifying people based on risk and who needs to do what based on risks like age, and comorbidities, and medication, et cetera, and that's been good to see, and also who needs to test and who doesn't, and who needs to get boosted and who doesn't. So, I think we're seeing a lot more thoughtfulness around that and hopefully we will be better prepared. What this has really shown us is that our public health system really was not what it needed to be. Right, so, hopefully everybody's re-watching the game tape and trying to learn, you know, how to do it better next time, because we're gonna need that. I feel like it was a trial run. Listen, it could have been a lot worse, but a lot of people died. It wasn't nothing. It was a very significant event in all of our lives, and plenty of people perished, and it's incumbent upon us to sit down and figure out how to do better next time, and my sense is that smart people are doing that. I hope they are. And it's not over, but at the same time.
Yeah, that's the thing, I'm acting like, yeah, so. We also saw incredible generosity and graciousness, and community in a way I don't think I've seen before, and that I can remember. So, we saw some good things too. Yeah. You mentioned the prescription of antibiotics, and, you know, kind of the misguidedness of that in the midst of all of this. What about Paxlovid? Like, that's something that's being prescribed quite a bit for COVID. Is there a sense of the efficacy of that? Is there a sense of the downstream gut health and immune system implications of doing a five day course of that? I think we don't really know yet in the sort of real life data what the downside is, but what I will say is, I think it's being prescribed a lot outside of the guidelines for who should get it in terms of age, or somebody who has a comorbidity that qualifies, and I think part of that is, it's pressure on the physician side to feel like I need to be able to do something other than to tell you to go home, and walk a little bit outside, and eat some vegetables, So, physicians want to feel like we can do something actively, and there's also pressure on the consumer side is that people want to know. They're like, "Look, we live in this modern world "where we can take a heart from somebody "and put it in somebody else, "and do all of these things, "like, you must be able to do something for me," and so, I think there's pressure on both sides and there's clearly efficacy in certain groups of people, but I think it is being over-prescribed and outside of the guidelines, and I think we'll have some data coming in soon. You know, for things like this, a short exposure probably isn't going to be problematic, but it's when we see people on longer courses or repeated courses, we'll start to have some data in terms of, you know, what the potential downside there is. Last time we spoke, it was a lot about how to live dirty, eat clean, and I have to ask, like, has there been any new revelation since we last spoke about the consumer products that we use? We've been talking about food, and pharmaceuticals, and the like, but what about beauty products? What about, you know, our soaps and the way in which we, you know, conduct our hygiene, and the clothes that we wear, and the dyes that those clothes are made with? Like, how are you understanding our habits around this and some things that we should be thinking about? Since we last convened, Rich? Which, goodness, it's been seven years. That's a long time. What's been exciting is to see people realizing like, "Oh, we were too clean," but what's also interesting is this idea that now you just have to put a probiotic in something, you know, probiotic shampoo, and probiotic, you know? So, we've gone from, "Oh, the anti-bacterial, to now the pro-bacterial," and the thing that I want people to remember is that it's less about adding something and more about not doing something that is harmful. So, thinking about what practices can we stop or decrease that are removing our healthy microbes, as opposed to, "No, I'm gonna add a microbe to something." So, just not washing as much is super helpful. I know I have rosacea, super sensitive skin, it's under, well, good control now. It's not flared up in years, and I credit part of that to the fact that I don't wash my face that much, and that really helps, and the same thing, you know, I have people who are suffering from hair loss, and I'm like, "Why are you putting "all this stuff in your hair?" Like, you've gotta give your scalp and the scalp microbes a little chance to regenerate, and so, I think because we are so product driven, we want to take something, and to do something, and I'm happy to see that we're having, you know, actually some pretty terrific pro-bacterial products compared to all the antibacterial, you know, this idea that we're gonna cleanse everything away. We've definitely moved away from that, and you look at products like some seaweed based products, a company like OSEA that's based here in Malibu that I think makes fantastic products. So, we're seeing much more of that, and I think the barrier for entry is lower because it's easier for somebody to put a product out now. You know, with platforms, you don't have to go through two or three of the large CPG companies to do that. So, we're seeing a lot of innovation, but I think the focus still should be on, again, your body is producing this stuff. If you think about stuff like the oil on your skin and in your hair, your body is producing the stuff that is custom produced for your body's pH, and your ideal skin type, and what do we do? We scrub that away, and then we put some store bought version on, and so, you know, we have to think about how we can work in concert a little bit more with what our body is already doing, and sort of, enhancing it, but not destroying, and then replacing. Right, it's analogous to the cough suppressant. If we're just putting soap on our face all the time and removing all of those oils, those oils are there for a reason, like, why are we getting rid of them? It seems like a good rule of thumb, although, you know, orthogonal to kind of our current modern day habits around some--
And my sister likes to point out, because I've been quoted about, you know, not bathing too much and stuff, and she likes to point out, like, she's like, "That's not everybody in the family." I like to bathe every day, and sometimes I'll go over there, and she lives nearby, and I would've, like, gone for a long run in the woods, and maybe done some yoga, and I'm like, "I don't smell bad, right?: And she's like, "Yeah, you don't smell "as good as you think you do." (laughing) It is interesting, there are so many companies and new products that are coming out that are, you know, sort of chemical free or more natural, and I think there's a sense like, "Oh, more natural is better," but it also has to be efficacious. Some of these products don't actually work. If they don't work, we're not gonna use them, but in the pecking order of, you know, like, there's the dirty dozen. What are the organic foods? So, in consumer products like chlorinated water, or fluoride in our toothpaste, or certain kind of shampoos, do you have a sense of the most important things that we should be paying attention to or getting rid of? Yeah, the really sudsy things like the sodium sulfate is a problem and people like that, because they like a sud, but some of those things, what they actually do is they disrupt the skin, the integrity of the skin, and they make it easier for pathogenic bacteria to penetrate, or they're really toxic to the, you know, the population of staph or corona bacterium that live on the skin, that are part of the skin's important ecosystem, and certainly things that have a lot of alcohol in them, because remember, before we had antibiotics, we had alcohol as our main antibacterial, and even now, if you go to get blood drawn, they put an alcohol swab to clean the skin. So, products that have a lot of alcohol in them are also potentially problematic for those fragile microbes. I want to touch on long COVID for a minute. I feel like this has become, like, a COVID... This is not meant to be, like, a COVID focused conversation, but because COVID is the virus that we're currently contending with, it feels appropriate to use that as a lens to talk about these other things that you talk about in the book. Long COVID is a tricky one. I feel like we don't really know what we're dealing with here, and you have some interesting information in the book about this, about what we know, and what we don't know know, and the relationship of gut health on this "thing" we're calling long COVID. One of the things with the book, I purposefully did not put COVID in the title. The book is called "the Anti-Viral Gut: Tackling Pathogens "from the Inside Out," and while COVID is definitely on the radar, there's a lot in the book as, you know, you've read it, about other viruses, about polio, about influenza, et cetera, and when it comes to long COVID, or postacute sequelae COVID, or long haul, or all the different names we have for it, one of the things we know a lot about is postviral syndromes. This is not the first postviral syndrome, it won't be the last. I think the problem, Rich, is that we weren't expecting it because we were thinking this is kind of like a bad flu virus, and postviral syndromes from flu are not as common, but think about AIDS. AIDS is a chronic form of HIV. HIV, the human immunodeficiency virus, causes AIDS, and it causes us prolonged disease. Now we have pretty good anti-retrovirals for that, but it's still a chronic condition. You think about hepatitis C can cause cirrhosis of the liver and liver cancer in many patients. You think about Epstein Barr virus causes mono, it's been linked to chronic fatigue syndrome and has been linked to MS now, multiple sclerosis, and it's linked to certain forms of lymphoma, so we have lots of precedent. In my world, in gastroenterology, we see something called post-infectious irritable bowel syndrome, post-infectious IBS, which is people who have had a clear infectious episode and then, lo and behold, you know, maybe they have acute symptoms, diarrhea, or something, nausea, vomiting, and those acute symptoms resolve, but then, lo and behold, they have irritable bowel syndrome and the GI tract is sort of never the same. So, we have a lot of experience with, if you think about some of the sexually transmitted diseases, like herpes, and human papillomavirus, so HSV, HPV, et cetera, we know there are acute and chronic forms of those and we also know similarly who is at risk for those chronic forms, and there are some outliers to that, but we know, for example, within women with sexually transmitted diseases, that the population of healthy lactobacillus bacteria in the vagina that produce acid to repel these viruses, that having lower levels can make you more susceptible to the acute process of after exposure becoming infected, and also to the chronic aspects of that. So, postviral syndromes are not new, but because this is a relatively new virus, we're getting familiar with what the postviral landscape looks like with long COVID, and there are now more than 200 different symptoms that are associated, and, of course, you know, a lot of this is reporting. Everything sort of gets put in, but we know what some of the more common symptoms are, fatigue, respiratory symptoms, brain fog, et cetera, and if we look at that, what we see are clear microbial differences in a lot of these patients, and a lot of this, we know from the CFS/ME literature with chronic fatigue syndrome, that researchers at Cornell were able to look at the microbiome and identify people who had ME/CFS based on what was going on microbially, and we've seen a lot of those microbial differences. We don't have a clear cut microbial signature yet, but we have some hints, and there was a study that was published in one of our GI journals. They followed 106 patients with acute COVID. They found a very high rate of chronic symptoms, about 76%, and in that 76%, they found significant microbial abnormalities in the people, the majority of people who went out to have chronic symptoms versus a minority who recovered, very distinct microbial patterns. So, it's difficult to sort out how much of that is cause versus effect because the virus itself can induce dysbiosis. This wasn't something we talked about, but the binding of SARS-CoV-2 to those ACE2 receptors can induce microbial changes, dysbiotic microbial changes, and then of course dysbiosis itself, as we've been talking about, is a risk factor for, you know, having worse outcomes, so there are both sides to that. We know that autoimmunity is an issue. We see autoimmune markers, many of those patients never had an actual autoimmune disease before, and they still don't have an autoimmune disease, but it's almost like a precursor, and we don't know what's gonna happen with some of those patients with the positive ANAs, and different non-specific markers of inflammation. Are they going to progress to an autoimmune disease or is that stage where they are, where they have an autoimmune marker, but not an actual autoimmune disease, a specific disease in and unto itself. We see EBV plays a role also. Yeah, that was the thing that jumped out to me. There's a sense that it might be a reactivation of Epstein Barr virus, and I didn't realize that, like, a huge percentage of people are harboring some, you know, amount of that virus. The majority of the population, and EBV is fascinating, the history, because if we look at, 100 years ago they called it idiopathic adenitis, idiopathic meaning unknown, adenitis, means the glands are inflamed, and then it wasn't until researchers at Hopkins, you know, a couple decades later linked this to mono and then just recently this year some groundbreaking breaking research linking EBV to MS, and the lymphoma connection has been made a few decades ago. So, it's still evolving, and the role that EBV, and reactivation of EBV may play in long COVID is still, you know, there's still a big question mark there, but again, we have precedent because we have lots of research, in the MS world, in the lymphoma world, et cetera. So, for people out there who are struggling, you know, I want them to know that even though the virus is novel, the science is not novel. We have a lot of data, we have a lot of researchers, a lot we do know, and there are lots of people working on it. The final thing I want to get into with you before I let you go, I've gotta know where we're at with the fecal transplant clinics that are supposed to be popping up everywhere. When you hear about all of these gut dysbiosis illnesses and the extent to which people like you can look at the gut flora, see what's missing, see what's proliferating, et cetera, it seems to follow that a lot of this could be resolved by simply culturing fecal transplants, and inserting them in people, and resolving this issue. So, explain why that is too simplistic a solution to these problems. If we look at some diseases, so if we go back to the Clostridium difficile, I was talking about Clostridium difficile, again, a bacteria lurking in many hospitals, some of us are colonized with it, but at low levels. You take an antibiotic, you kill off a lot of your healthy bacteria, and now the C. diff that's either there or that you've acquired when you went to visit your grandpa in the hospital or if you yourself were hospitalized, is now proliferating and you have C. diff colitis, and you have this severe diarrheal illness, a stool transplant in that setting, in the study published in the New England Journal of Medicine a couple years ago, they actually had to stop the study early because the group that received the stool transplant did so much better than the group that received antibiotics, and when you think about it, a problem that's caused by antibiotics, the likelihood you're gonna have, you know, some fantastic solution from antibiotics is pretty low. but FMT, fecal microbiota transplant, the technical term, was shown to be vastly superior to the antibiotic treatment, vancomycin, that had here to fore been the standard for this, and the reason that it works so well is because that's an acute problem. Your healthy bacteria have been killed off by this dose of antibiotics. You've acquired this bacteria, and we're gonna crowd it out with a lot of other healthy bacteria, and it's gonna take care of the problem. When we look at more chronic problems like autoimmune diseases, like a problem of Crohn's disease, or ulcerative colitis, or autism, or Parkinson's, or a lot of these things that we're looking to FMT as a solution. I think the biggest problem is that the studies have been short-term. You're not going to cure a chronic disease giving a stool transplant for a week, or two weeks, or maybe even two months, and the other problem is, we're not looking at what we're feeding those gut microbes. So, there was an autism study looking at FMT in conjunction with diet over several months, and that study really stood out head and shoulders above the other studies, whereas FMT alone, and the same in the GI world, just a few weeks ago, I was actually on vacation in Turkey, and so, the time, you know, we were seven hours ahead from DC, and one of my GI colleagues, you know, we all geek out on this stuff, texted me, and it was, like, three in the morning, or something, about this study that just came out from Johns Hopkins finding that clostridium difficile infection was actually potentially linked to colon cancer, and he's a person, my colleague at Georgetown, really great guy, Mark Matar, who does a lot of the fecal transplants, and so, I saw it, and then we immediately started this text exchange and my husband was like, "It's 3:00 A.M. in Turkey," but the reason it was so exciting for us is it links the antibiotic use, because, why do people get C. diff? The vast majority, it's from antibiotics. You have some more sporadic or community acquired, but it's primarily related to this antibiotic use and maybe exposure in the hospital, and so, this is a potential link to antibiotic use and malignancy, which is something that I've worried about for a long time, but, again, it speaks to the acuity of that process. You're trying to cure ulcerative colitis, or put it into remission, or Crohn's disease, that's a long-term process. Those stool microbes for C. diff, you're able to control the acute infection, and then the microbiome reverts back to something closer to baseline gradually over time, but with colitis, or Crohn's, or MS, or Parkinson's, you need the microbiome, those changes to last, and so, in the studies where they combined it with diet, they saw very different results. It was another study that just came out just a few weeks ago and this was a small study from India looking at ulcerative colitis, and they did the FMT with dietary change. Very dramatic results, very different results, much higher rates of response and of remission. So, it's intuitive, Rich, that you've gotta continue to... you can't feed the microbes Doritos and cheeseburgers. Yeah, it's like plant a seed in the sand and walking away from it, and being disappointed that it doesn't grow versus watering it, and feeding it, and tilling the soil, and all of that. I mean, conceivably, it makes sense that even with a chronic condition, you would be able to resolve it if you had periodic fecal transplants on some kind of schedule over a very extended period of time and a very specific diet that is intended to fertilize those transplants, so that they're allowed to flourish, and grow until they become sort of self-sufficient. And the other thing we have to consider is, what is the quality of the stool that's being transplanted? So, is the stool from somebody who's eaten at McDonald's every day? The vetting process is very basic currently. So, they exclude certain infectious diseases. They test for syphilis, and HIV, and hepatitis, and various things, and there's certain conditions that will exclude you from being able to be a donor, and medications, but there's nothing about, I want to know like how many vegetables do you eat? I'm seeing a new product category, you know, on Goop. I mean, I always said, if I were getting a stool transplant, I would be going to Tanzania, and getting some stool from one of my Hadza tribe brothers or sisters. I don't want stool from somebody who's been eating at McDonald's every day. So, in the studies where they looked at the quality, the microbial richness, diversity, robustness of the stool, you measure short chain fatty acids. That's night and day. It's like any other transplant. If you're getting heart transplant from an older person who lived a very unhealthy life, you're gonna have a different outcome, if you're getting at heart transplant from a young, healthy person, and in this case, I would say age, maybe less so, but because I would take some microbes from Mike Fremont. Yeah, Mike, could support himself for the rest of his life selling his-- Selling his stool, yeah. So, we have to look at, that's great, what are we feeding the microbes that are being transplanted, and what is the quality of the transplanted stool? And I think in the future, we'll see some new innovations. So, we'll see, instead of somebody else's stool, where we do have to worry about infectious things, and that's why getting stool from an intimate contact can make it more convenient. You're already swapping body fluids, but there may be issues with the quality of the stool there that are not ideal is, can we amplify our own bacteria? Can we take our existing faecalibacterium prausnitzii, and maybe take them out of the body, and amplify them in some way, maybe with an ideal growth medium, and then reintroduce them, and, of course, Rich, we can do that with food. We could do that with food. That's the great thing is we don't have to sit around and wait for these moon shots to become accessible to all of us. There are all these things that we can do every single day. It's back to the original point that we opened this conversation with, which is the resilience of the human body and the ability of the microbiome to adapt, and, you know, throughout your book, I mean, as you mentioned, a third of the book really is this plan. You've laid out this entire plan. It's about mastering your mind, securing defenses, changing your environment, rethinking these therapeutics, and you walk people through it step by step, very practical things that every one of us can do, including all these recipes for different kinds of foods that are specific to optimizing the health of our gut, and I'm excited for people to read it. I think it's really powerful, and it's empowering, and that's the point. It's not just an academic pursuit to try to understand the microbiome, but to really give people tools that they can implement into their lives to take better control of their health trajectory. And I think it is an optimistic message. I find it reassuring, this information. There's stuff you can do, because, the fear mongering, you know, and that's how you sell stuff to people is you make 'em afraid, right? And I'm not interested in doing that. I'm interested in making sure people have the information to empower themselves, so that they don't need my help, quite frankly. Yeah, and if somebody is looking for your kind of help, maybe they're not able to come and see you, but what is a way or a resource that's available to people who are trying to find someone who has your type of specialty in an integrative sense, in their respective area? Yeah that's--
Is there a way to do that? That a tough one, Rich, we don't currently have an association of integrative gastroenterologists, although Will B., and myself, and Jerry Mullen, and this great guy, Desmond, a British gastroenterologist, who I met at ICNM, I'm blanking on his last name, but he runs a clinic in the UK treating patients with IBD, plant-based diet. So, there's a handful of us, and we've been chatting about it, and the idea wouldn't be, you have to be a plant-based physician to be part of this. Not at all, it's just this idea of people who believe in the concept of food as medicine for treating digestive disorders. So, I think that you've gotta ask some questions, and you might have a gastroenterologist who maybe isn't particularly focused on this, but is open to this, and maybe you're working with a nutritionist, and the gastroenterologist is open, and I think, you know, my evolution from a more... I'm a conventionally trained gastroenterologist, but from somebody who wrote a lot of prescriptions, and practiced more conventional medicine, to somebody who now believes fervently in the power of food as medicine, and what the individual can do in addition to prescribing medication when needed. That evolution really came because of the patients who were generous enough to share what they were doing with me when I didn't know, when I was like, "Really, that stuff works?" And they were like, "Yeah, this is..." I'm like, "How is it that you're... "I scoped you, and your ulcers "are all gone from your colitis. "What are you doing?" And they'd be like, "Well, as a matter of fact, "this is what I'm doing. "I've changed my diet, I'm doing this, I'm focusing on..." And so, it was really a patient led evolution, and so, I always tell people, like, don't break up with your gastroenterologist unless they're just really an asshole, in which case, absolutely do, but bring them along. So, maybe you find somebody, a nutritionist who's well versed, who can help, and you make sure that that gastroenterologist is open to the idea of what you're gonna do, and I always say, tell them, like, don't hide. Like, say, "Look, I know you want me to take this drug, "this biologic, and I'm aware that this could help me, "but I'd like to try something else right now "and I feel like my disease is sufficiently controlled, "that that's safe for me to do." You know, "Do you agree?" And this is what I'm gonna do. I'm gonna try this diet, and I'm gonna start meditating, and going for a walk in the woods, and whatever else, and we'll see how it goes, and if it doesn't work, I'm gonna come back and get that drug that you're telling me could help, even though it could potentially cause an infection and give me cancer, because I think I need it at that point, but I'm gonna explore this stuff. So, I think the way we change a medical community is we have to change it from the inside, and if everybody abandons their doctor and seeks somebody else out, that's not gonna work. So, bring your doctor along, help to open his or her eyes about what can be done and create those bridges between the other practitioners that you were using, or it may even be a book that you've read. Books are fantastic, but you really want to find that practitioner who can be on that journey with you. I think that's a really important part of it. Beautifully put, the communication, and on the subject of books, just bring this book. This is the galley copy. It doesn't have the nice, new cover on it, but maybe pick up "the Anti-Viral Gut" and bring it to your gastroenterologist, if they haven't read it yet. The worst thing that can happen is you improve your health. There you go. Seven years is too long in between our conversations. I have so much reverence and respect for the work that you're doing, and, you know, the subject of the microbiome is just endlessly fascinating, and I think it's really important work, and the fact that you've found a way to communicate what is very complex in a way that's not just understandable, but very practical and actionable, I think is a great service, so thank you for that, and it's always a pleasure to talk to you, and hopefully come back and talk to me some more. Thank you, Rich, and I just have to say too, that we've known each other a long time and I've watched in awe as you built this incredible community, but I also just want to call you out for what I think was a really incredible work you did during that dark summer of 2020 with Black Lives Matter and our country was really hurting, and still is in a lot of ways, but I think you personally just did so much to move us along there, so thank you for that. I appreciate that. It wasn't much, but it was a little bit that I could do during that difficult time, so thank you. Thank you. Obviously, pick up "the Anti-Viral Gut," available everywhere. Any other place that you want to direct people to-- Yeah, so--
To learn more about you. Robynnechutkan.com. I have a difficult to spell first name, R-O-B-Y-N-N-E, and an equally difficult to spell last name, C-H-U-T-K-A-N. So, robynnechutkan.com. We're sort of transitioning from gutbliss.com to robynnechutkan.com, and we do have lots of great free resources there. We have these gut guides to different conditions that talk about, you know, diagnosis and therapeutics, and we have a great blog with lots of great tips, and we don't sell anything or promote anything. Right, and I think you're still Gutbliss on some of the social media. I'm still @gutbliss on IG, but planning a change. Switching it up, re-branding.
A little brand identity happening, yeah.
All right. Well, like I said, you're always welcome here, and thank you, that was amazing and wonderful. Thank you so much. It's always so good to be here. Peace to the audience. (upbeat music)
