Jun 28, 2022

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Scot: You know, you're not just eating for yourself. You're actually eating for 39,000,000,000,001. What? Well, today we're going to talk about the microbiome and men's health.

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. He brings the MD. It's Dr. Troy Madsen.

Troy: Hey. I'm excited to hear what's inside me. I'm curious and excited.

Scot: All right. I bring the BS. My name is Scot Singspiel. He brings the mics. He is Mitch.

Mitch: Are we talking about poop again?

Scot: No. We're talking about the . . .

Mitch: I mean, he's here.

Scot: Well, maybe. I mean, our guest is Dr. John Pohl. He's a gastroenterologist.

Mitch: I know. He's back.

Scot: And just like marathoners can never stop talking about marathons, gastroenterologists are going to probably mention poop in a conversation.

So, Dr. Pohl, it's great to have you on the show.

Dr. Pohl: It's so great. Thank you for allowing me to be speaking with you guys today.

Scot: All right. So first of all, I'm just curious, John, are all gastroenterologist experts on the biome, or is it just you? For me, the biome wasn't something I even knew about until kind of just recently, right? And I don't know how widely known the biome is and what it does. Most gastroenterologists, are they experts on it, or mildly know, or what's that look like?

Dr. Pohl: Well, I mean, I think we've all known for a while that poop has bacteria in it obviously.

Scot: There we go. We got it out of the way, Mitch.

Dr. Pohl: We got that done.

Mitch: Good. Thank you.

Dr. Pohl: I think that people really didn't start thinking about the microbiome until about 20 years ago, maybe 25 years ago. And people started realizing that the type of bacteria you had in your intestine and other parts of the body as well really affected health outcomes.

Scot: So normally, we think of bacteria as bad things, but these are good bacteria.

Dr. Pohl: Right. And most bacteria in your body don't care that you're there. They're not good or bad. That's the biggest group. The next group of bacteria, they're probably beneficial. And then the smallest group is the bacteria that are probably harmful.

Scot: What is the microbiome then exactly?

Dr. Pohl: So I like to think of our intestinal tract like a coral reef. It's like a big Jacques Cousteau episode. So instead of the thousands of species of fish, and crabs, and things like that, we have bacteria.

What's really fascinating to me, and I know we're going to talk a little bit about bacteria and health outcomes, but there's also the microbiome in the gut associated with fungus. Very helpful as well.

And then the thing that is really exciting right now is called the virome, which are all the trillions and trillions and trillions of viruses that interact with the bacteria that probably affect the whole microbiome as well.

So you're just dealing with just literally trillions of entities affecting your health.

Scot: And in the stomach, the microbiome, does it primarily help with digestion? Is that kind of why it's there?

Dr. Pohl: Well, the stomach has stomach acid, so you really don't get a microbiome there. Now, that's a very interesting question because if someone is on an acid blocker for a long period of time and they don't have any stomach acid, they can get bacteria in there, which sometimes can cause problems.

But you're mainly dealing with small intestinal absorption. So your small bowel absorbs food, and your large bowel, your colon, kind of helps to collect what's leftover and makes you poop. And that is where the action takes place, in the small intestine.

Scot: And that's where the microbiome is?

Dr. Pohl: Well, it's all the way through. I mean, you even have microbiome in your skin, in your ears, in your nose, obviously. But the main thing, where the vast majority of the bacteria are present, is in your small and large intestine.

Scot: So I've had this little theory, and tell me if this little theory is crazy or not, that when I eat or any of us eat, not only are we eating for ourselves for the nutrition that we get out of it, but we're actually trying to eat to keep this microbiome healthy because it does have such impacts on our overall health and how we digest food and absorb nutrients. Is that true?

Dr. Pohl: That's exactly right. And then the weird thing philosophically to think about it is "What does it mean to be me?" If you're supporting your gut health and all the trillions of bacteria, what are we? But that's a whole other story. That's something I find fascinating.

Troy: No, it is fascinating. And I don't know the answer to that. What percent of our body mass is really bacteria and all these living organisms that are just a part of who we are and affect who we are? I've even heard just affect the way we think, all those sorts of things as well. So it is very fascinating.

Mitch: Is anyone else feeling itchy?

Troy: Yeah, exactly. Going to drink some anti-bacterial hand sanitizer or something.

Mitch: Yeah, with another gross-out episode.

Troy: But I think it does. It kind of creeps people out to hear that. And like you said, John, it's something that it seems that we've really started to recognize a whole lot more over the last decade or so.

How often does this really play into what you do on a daily basis, though? It's kind of interesting to know, like, "Wow, we have this microbiome," but in terms of what you do in treating disease and talking to patients about their bowel health, all those sorts of things, how often does the microbiome come up? And along with that, how often are you actually doing things to try and potentially change that or make it healthier?

Dr. Pohl: In terms of what I do as a pediatric gastroenterologist day to day, I probably talk about the microbiome quite a bit in certain settings. Some of the big things I see are diseases associated with gut inflammation, whether it's infectious or inflammatory.

So let's talk about things that are infectious. So there is an infection C. diff or Clostridioides difficile, which is associated with chronic antibiotic use where you can get very bad diarrhea that sometimes doesn't respond to antibiotics. And if you're not responding to antibiotics, we actually have approval at our Primary Children's Hospital to do colonoscopies, and we put donor stool into the colon. We clean out the colon and put donor stool and that gets rid of the C. diff.

Troy: So let's pause there just for a second.

Scot: Yes, please.

Troy: Mitch, did you catch that?

Mitch: I sure did. I sure did get that. Thank you. Yeah.

Troy: In layman's terms or layperson's terms, you're talking about taking poop from another person and then taking that . . .

Dr. Pohl: We use a parent.

Troy: From a parent, interesting. And then inserting that stool sample, that poop, from a parent into the child's intestines.

Scot: And with the thought that you're getting those good bacteria. I mean, you told us that not all . . . But the beneficial bacteria in there to overpower the bad bacteria.

Dr. Pohl: That's exactly right. And in terms of other things you can do, we will use probiotics for other diseases as well. There's some very good evidence that patients that have inflammation on the left side of their colon, so the part of the colon that kind of empties right into your rectum and anus, if it's fairly mild . . . For example, with ulcerative colitis and sometimes with Crohn's disease, there are certain probiotic regimens that you can give that can keep you in remission.

Some of these are extremely expensive regimens. And they are not prescriptions, so you have to pay for them. But that's actually very helpful as well, which I find very interesting.

Other things to think about are, in children, there is some evidence that giving probiotics with healthy bacteria are helpful in terms of getting eczema and atopy of the skin.

And then something that you guys deal with in terms of the adult world there really are some interesting data out there. In terms of people who have coronary artery disease, it puts them at risk for heart attack. Eating food that is high in animal fat increases what are called phosphatidylcholines, which can increase your risk of atherosclerosis. And also having a very good gut biodiversity in the intestine is very helpful in terms of protecting against adult-onset diabetes, also known as type 2 diabetes. So there are some really fascinating data out there.

Troy: Yeah, the more you hear about the microbiome, the more I think that eventually . . . Obviously, we talk so much about genetics, and genetics is the future of medicine. I almost kind of think that we're going to start moving more toward microbiome. You talk about all these effects. Like you were saying, heart disease. And maybe I've seen something at some point about Alzheimer's. I don't know. That kind of rings a bell, but maybe you've seen something there. But so many varied diseases that are affected just by these bacteria in our body.

Dr. Pohl: Yeah, there does appear to be an association, not very clear, between dementia, ALS, Parkinson's with the microbiome and brain outcomes. What's really interesting is there appears to be some type of association between the vagus nerve, which is one of the longest big nerves that goes down from your brain, down the side of your esophagus, into your intestinal tract, in terms of what happens in the microbiome and signaling to the brain. And that can lead to increased inflammation in the brain.

And so there does appear to be an association with things like Alzheimer's, dementia, and your type of microbiome. But these are very difficult studies because we don't know what these people were eating before they did the stool studies or got small intestinal fluid to see what was going on.

So the point being is that there appears to be an association, but we need a lot more information before people just start taking tons of probiotics for this, because I think it would be the wrong thing to do.

Troy: So apart from probiotics, anything else you recommend just from a dietary standpoint to have the healthiest microbiome you can have?

Dr. Pohl: Yeah, so the first question is should you take probiotics? And I generally say no, unless it's specific conditions, mainly because there's so much variation in terms of what type of bacteria you're getting and how much is in each capsule or little packet. It's not very regulated.

So there are certain situations where I might recommend it. For example, taking it for traveler's diarrhea and things like that, certain mild types of inflammatory bowel disease.

So that goes back to one of my simple truisms in life is if you want to live longer, eat less and exercise more. There is a lot of evidence that being mildly athletic, and I'm just talking simple cardio, such as just simple walking, really tends to predispose you to more healthy type bacteria. No one really knows why that is, but exercising tends to self-select for more healthy bacteria.

Now, at that time, you may be deciding to eat more healthy, and that may be part of the issue. But there appears to be a benefit from exercising and how it influences your microbiome.

And then diet. What's really helpful in that setting is, again, not the bacteria, but how you're feeding your bacteria. So giving things that are called basically prebiotics. You can buy prebiotics over the counter, but why do that when you could just eat healthy? So fruits, vegetables, beans, whole grains, very simple groups are highly effective in giving you a better, healthier microbiome, specifically things like garlic and onions and leeks, asparagus, bananas, seaweed. Seaweed has become more ubiquitous in our diets and grocery stores. That's another way you can find things very helpful as well.

Scot: What about fermented foods? I've heard fermented foods like yogurts and horseradish. Not horseradish. I don't know what.

Mitch: Kimchi or whatever.

Dr. Pohl: Absolutely.

Mitch: I live with someone who has five jars right now of foul-smelling things that are fermenting wildly in hopes of improving the probiotic. Is this accurate? Is this a good thing to be having in my home?

Dr. Pohl: Right. Maybe I'm wrong. I just don't think you should eat things that stink. That's just a big thing for me.

Mitch: Cool. I'll take that to the bank.

Dr. Pohl: You're exactly right. So the foods you're mentioning often have what are called short-chain carbohydrates, which are basically fiber-type supplements, fiber-type derivatives, and that's very healthy for the bacteria in your small intestine.

The way I look at it is very simple carbohydrates get absorbed very, very quickly and metabolize very quickly. They don't reach deep into your gut, and that's why you need some of these other foods that I'm talking about.

The only reason I bring up being careful about fermenting your own food is there have been some examples . . . and this is super rare, but just keep in the back of your mind that some of the fermentations end up producing toxic byproducts. So if you don't know what you're doing, you just need to be careful because there have been case reports of toxicity with some of these items, self-made fermentations.

Scot: As men, what do we do that either hurts or helps our microbiome? Are there any particular things that men do? Maybe we eat too much meat. Is that good or bad for microbiome? Are there other things?

Dr. Pohl: Oh, yeah, I think I think that's exactly right. So I think men often have a problem with their diet and just eating healthy. In all I've said, I haven't provided anything super complicated. Make sure you're increasing the amount of fruits and vegetables and whole grains and beans in your diet. It's helpful.

Americans are terrible at exercise. When I talk to people about this, I'm not asking people to be marathon runners. I'm asking them to walk in their neighborhood for 40 minutes, three to four times per week. That does appear to be protective.

Strangely, and for reasons that are not entirely clear, sleep really affects the microbiome. If you're not getting enough sleep, you tend to get the more inflammatory-type bacteria. So that's a big deal as well.

And then excessive alcohol use really affects your microbiome in detrimental ways, which can cause downstream problems, like cardiovascular health and diabetes. Same with tobacco use.

Scot: And let's say that somebody maybe . . . I mean, I don't know. Would you know if you had an unhealthy microbiome? And if so, you decided, "You know what? I'm going to start rebuilding. I'm going to start eating healthy, do the right things." How long does it take to rebuild that? Is that days, weeks, months, years?

Dr. Pohl: So no one is exactly sure. It probably would take days, to be completely honest with you. Your intestinal microbiome has a lot of what they call plasticity. Often you can really injure it in terms of removing bacteria from your intestine and it'll come back healthy very quickly. We see this with some of the bad bacteria that you can get, like salmonella or shigella. After it clears, it can come back very, very quickly.

I don't think there's ever a need to check your microbiome. There are labs that will check your microbiome for you. Some are trusted. Many, in my opinion, should not be trusted in the least bit and you're spending hundreds if not thousands of dollars.

But the simple way around that is to say, "Okay, I'm going to do aerobic exercise, I'm going to a well-balanced diet, I'm going to try to get sleep, and I'm not going to do excessive alcohol or tobacco use." And you can pretty much be guaranteed your microbiome will be healthy.

Troy: I love it, John. You just quoted, essentially, more or less, what we refer to here as the Core Four. And we just keep coming back to it. It's so great. And we just came back to the Mediterranean diet as well. I mean, it sounds like you're basically talking like Mediterranean diet is optimal for your microbiome.

Dr. Pohl: Absolutely.

Troy: Like you said, get your sleep. Make sure you're eating well. It makes a huge difference.

Dr. Pohl: Absolutely. These little critters in your intestine, whether they be fungus or bacteria or viruses, are all there to help you. It's not just your gut health. You have to think about your whole body holistically. There appears to be evidence that it can affect coronary artery disease and reducing your risk of heart attacks with a healthy microbiome. Potentially prevention of adult-onset or type 2 diabetes.

And just like you talked about, there appears to be pretty interesting evidence that there's some aspect of dementia prevention and perhaps prevention of anxiety or depression. Again, those studies are hard to do, but there is some intriguing evidence.

Troy: Wow. So even mental health. That's incredible.

Dr. Pohl: Absolutely.

Scot: So bottom line, just like Troy said, it's the Core Four. We don't necessarily know how much the microbiome impacts our health. We know to some extent it does. But what's really the downside of trying to get a little bit more exercise, trying to eat a little bit more healthy?

Dr. Pohl: That's right. And don't do any type of fecal stuff at home.

Scot: Okay.

Troy: Don't eat poop. Just don't do it.

Scot: Do you hear that, Mitch?

Mitch: I hear it.

Scot: Okay. Don't do fecal stuff at home.

Mitch: On it.

Scot: And on that note, I guess we wrap up the show. Thank you very much, Dr. Pohl, for being on "Who Cares About Men's Health."

Dr. Pohl: Thank you. It's been a real pleasure.

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