Nutrition Essentials: Feeding Your Gut’s Microbiome with Christine Lee, MD

Podcast Transcript

John Horton:

Hello and welcome to our first Nutrition Essentials podcast, an offshoot of our popular Health Essentials show that comes at you new every Wednesday. I'm John Horton, your host. So what exactly is nutrition essentials? Basically, it's a podcast focused on diet and how it relates to every aspect of your health. It's going to look at how what you eat affects specific parts of your body, heart, eyes, lungs, muscles. Well, you get the picture once a month. We'll be joined by registered dietician, Juli Zano and another Cleveland Clinic expert to talk about these food body connections and how you can leverage them to live and feel a little better.

Julia Zumpano:

That's exactly right, John. I've been a registered dietician for almost 20 years and have seen firsthand how what you can eat can make a huge difference in your health.

John Horton:

This is why we're so excited about nutrition Essentials, Julia. And to get us started on this journey of food and health knowledge, we're going to begin in an obvious spot the gut. Now, anyone who has rolled the dice on a gas station burrito and lost that gamble understands the relationship between food and your INDs, but those ties go far beyond the occasional crumbly tummy after a questionable meal. The dietary choices you make day after day set the tone for how efficiently your gastrointestinal system operates. So today we're going to chat about how food affects gut health, while also exploring the digestive process from start to finish. As you might guess, Julia will handle the input part of that process by looking at the food we eat. The long and winding road to the eventual output falls in the domain of our second guest. We'll let Julia make that introduction.

Julia Zumpano:

Thanks, John. As we know, everything you eat and drink makes its way into your stomach and eventually works through your digestive system. What you consume will help you determine how well your system functions. That's why dieticians work closely with gastroenterologists like Dr. Christine Lee to avoid or manage GI issues. I look forward to talking with Dr. Lee about our complimentary roles and how food can be viewed as medicine when it comes to your gut.

John Horton:

Oh, it should be a great conversation, Julia, and by the time we're done, I have no doubt our listeners will have a lot of information to digest. So let's get started. Dr. Lee, thanks so much for joining Julia and me for the debut of the Nutrition Essentials podcast. We couldn't have asked for a better first guest.

Christine Lee:

Thanks John. I'm just so happy to be here with you today.

John Horton:

We're so excited that you're with us. So food as it relates to gut health is just a massive topic with so many different conditions that come into play. There's irritable bowel syndrome, which is as unpleasant as it sounds. There's heartburn, gerd, a more serious form of acid reflux. There's diverticulosis, there's plain old gas and bloating. But if there's one common thread among all of these issues, it would be problems related to the exotic sounding world of gut flora and the microbiome. Dr. Lee, can you educate us a little bit about this ecosystem that's in our gut?

Christine Lee:

Yes, it is a very common topic or a common question that arises at meetings or dinner tables. Our digestion plays such a significant role in our life and in our health and all the systems, whether it's your neuro system or endocrine system or digestive system, they all kind of work intertwined. So you want to make sure all your systems are working at its best. For the GI gut aspect, the microbiome is best to explain by saying healthy gut bacteria or what we call gut flora. These are healthy bacteria that help you or aid in digestion so that you can digest more efficiently and without excessive gas or discomfort or motility issues. Unfortunately, microbiomes can get disrupted with multiple different things that arise in one's life, meaning antibiotics, certain medications, surgeries that alter your anatomy, stress, sleep, deprivations, what have you. So when those microbiomes are disrupted, it can play havoc in your digestive tract. So it's important to understand what your microbiome is and how you can try to protect it, meaning minimize these mishaps that stresses your microbiome and should one of those things happen, how to recover your microbiome in the safest way.

John Horton:

Yeah. Dr. Lee, I always find it so interesting when you talk about bacteria, we always think bad bacteria just doesn't sound like something that that's helpful to us, but it really is essential in our gut for everything to work, right?

Christine Lee:

Absolutely. Those microbiomes help in digestion breakdown of the food particles releasing nutrients that your body can absorb. So it plays a protective instrumental role in the system of digestion.

Julia Zumpano:

Dr. Lee, correct me if I'm wrong, we have good bacteria and bad bacteria, so we want to focus, we are heavily focused on the good bacteria, which creates a healthy microbiome, but those bad bacteria, they overgrow, that can create a lot of issues too.

Christine Lee:

Absolutely. Absolutely. That's so correct. So the good bacteria has multiple roles. One of them is to keep the bad bacteria in check, meaning the good bacteria suppresses the population or reproduction of the bad bacteria. So they have a predictive role for, well, one. Secondly is the digestion itself, where it helps break down the particles, the proteins, releasing the nutrients, and then the third aspect is to keep things moving. You want to make sure that the intestinal tract is not stagnant and that things are moving top to bottom in an efficient way. It has multiple aspects.

John Horton:

Yeah, there's just so much going on down there. It makes you realize when you hear your stomach doing things, that there's a lot happening.

Christine Lee:

That's absolutely right. And then all those things actually gets more challenging with age. Like anything in life for wear and tear, there's more opportunities for mishaps and things to go awry. So more important than ever as we get older, to pay more attention to our body to just kind of protect it prevention's key, but should those mishaps occur, how to just kind of regain your healthy flora and maintain your healthy flora.

John Horton:

And that's where I want to go to next with you, Dr. Lee, because our goal here is to have this kind of flourishing microbiome. I've seen it described as a garden, and you want everything just perfect there so things grow and work the way they're supposed to, but I'm guessing it's not always the case with people that it works like it should. How does it get thrown off balance?

Christine Lee:

So it gets thrown off balance unfortunately in multiple chances. One of the common things is if one suffers from a bacterial infection like an ear infection or a UTI or a skin infection, and you get prescribed antibiotics rightfully to combat that bacterial infection that you have. Unfortunately, all antibiotics work in killing bacteria good and bad, unfortunately. So they try to target the bad, but unfortunately what it also does is kills good bacteria as well because it's not a smart bomb. So in the attempt of taking care of the bad bacteria, if you lose too many of the good bacteria in the process, then it provides an opportunity where the bad bacteria in your gut to overtake the population over the good bacteria, and that's where the bad bacteria or bacteria overgrowth can occur.

John Horton:

Now you mentioned antibiotics. Now what about just regular medication? I know I'm an allergy sufferer and I go through stretches where I pop Claritin regularly. Is that going to cause me problems down low?

Christine Lee:

It can can some antihistamines or anti-allergy medications can combat the histamine release that helps you with the allergy symptoms. But the unfortunate unwanted side effects that it comes with is it actually can dry things out, including your gut, and it can slow down your motility, meaning how fast your stomach empties, how fast your small bowel moves, and how fast or how slow your colon moves are unfortunately affected as a side effect of these medications. And oftentimes they have constipating influences that one is not aware of until it's too late.

John Horton:

Nothing's ever easy.

Christine Lee:

So unfortunately, it's not limited to just allergy medications. There are a long list of medications that have unwanted side effects, bladder spasm, medications, or even some heart medications that control your heart rate and blood pressure can also slow down your motility in the colon. Now again, heart always trumps the colon, and so you have to take it. That's more important, but understand that they come at a cost. So if it comes with an unwanted side effect, then you want to be proactive and take some probiotics or medications that help combat the motility slowdown, meaning take some laxative so that you don't get the constipation. You want to be proactive. We're not saying don't take the heart medicine. We're saying if you are on such medicine, you need to be aware so you can be proactive and take things to offset the unwanted side effect that it comes with.

John Horton:

Yeah, counterbalance that a little bit.

Christine Lee:

Unbalanced. That's excellent. That's right.

Julia Zumpano:

Right. Dr. Lee, I have a lot of my patients that are suffering from reflux and they are taking any antiacid over the counter medications. Do those affect your gut health?

Christine Lee:

It can. It can. So acid reflux is unfortunately extremely common. So a lot of people suffer from that ailment and it's important to figure out why they have acid reflux. So not all acid reflux the same. Some people have acid reflux because they have what we call lower esophageal sphincter incompetence where the end of the esophagus, where it meets the stomach becomes too lax and everything just sloshes up. So that's one form. Another form is that they may just hyper secrete, they make too much stomach acid, so it just splashes up outside the stomach area. Other acid refluxes is because the constipating effect when you're extremely constipated in the colon, it slows or backs up the small bowel. And if that happens, then the stomach kind of gets backed up and it can't empty properly. So what can't go south goes north. So heartburn, it's important to tease out what type you fall in and if you treat it, if you're constipated and you're taking acid reflux, then obviously it will help with your symptoms, but it can definitely worsen your gut health or gut motility or how you feel or how you're experiencing your gut motility.

So it's important to figure out what the root cause is and treat that rather than just simply covering it up and taking symptomatic relief with acid reducing medications.

Julia Zumpano:

Sure, I love that. I love that. I always try to hit lifestyle first and see what other interventions we can do to help minimize the symptom versus treating. Obviously with an over the counter medication or prescription medication, we always want to try to incorporate better lifestyle habits.

Christine Lee:

That's absolutely right. I'm always shocked when I have patients that are on, I don't want to say obscene amount of acid reducing medications, and they're so frustrated they say, I take twice what the doctors tell me and it still doesn't work. Well, if that's the case, you really want to revisit the source of the problem and kind of get to the root. And if it's because they're severely constipated by treating the constipation, some of those patients get complete relief and they're off of acid reducing medications because now things can go south and it's not reflexing up, and so they get great symptomatic relief. So those are the success stories. You want to treat the root of the problem rather than just treat everybody with acid reducing medications.

John Horton:

So Dr. Lee, we've talked about a couple of these factors that you brought up like antibiotics, medications. I think you had mentioned surgical history before, but obviously the big one and the reason why we're here today is to talk about diet and what that does to your gut. Is it really that big of a factor when you look at the microbiome and just how that flora is?

Christine Lee:

It really can be. And the reason why is certain food types we know causes or takes longer to exit the stomach. So high greasy foods, fatty foods, fried foods, certain foods just take so much time, it takes more time to process through your gut. So it slows everything down. And like all things in life when things slow down, it gives an opportunity for bad bacteria to overgrow and overpopulate because the motility has been slowed down so much that there's less circulation, less movement, less things continually cycling through that things back up. And so it's important to make sure if you do indulge in these food groups, the fatty greasy foods, you want to do it in moderation and you don't want to do it all the time. So you want to make sure you're eating the healthy foods that are rich in healthy probiotics or even prebiotics that are simple and easy and that promote motility that way if you do splurge from time to time that they're in moderation and not in over access.

Julia Zumpano:

I couldn't agree more, Dr. Lee. What I tell my patients often is really trying to focus on fiber in their diet. So fiber is what is a prebiotic, it's what feeds the probiotics, the bugs, the good bugs. So we want the fibrous foods to feed the good bugs and they will flourish and grow. Not only does fiber help your good bacteria grow, but it also creates more of a healthy stool that's easier to pass, more formed. And fiber can help with lowering blood pressure and lowering blood sugars and cholesterol. We have so many great benefits of dietary fiber, but it really all begins in the gut and having regular fully formed and feeling like you fully eliminate when you have a bowel movement, that's very, very important. Making sure you're clearing out your system is ideal. And the foods that have fiber are really the foods that grow from the ground.

Things that we know are plant-based. So fiber is abundant in grains, whole grains like oats and quinoa and fruits and vegetables, nuts and seeds, beans, all of those are all phenomenal sources of fiber. And a majority of Americans aren't anywhere near getting enough fiber. Recommended. Dietary fiber intake is between 25 to 35 grams a day. Most Americans are barely getting 10 grams of fiber a day. So we definitely need to as a whole increase our dietary fiber intake and that will resolve a lot of these issues we've been talking about is gut microbiome that's flourishing in bad bacteria or constipation or reflux due to maybe some of that constipation. So I think it's extremely important to really heavily focus on fiber.

Christine Lee:

Julie, I could not say that any better. That is so important. You said everything right on one of the misnomers is that patients grossly underestimate the amount of fiber that they actually consume. And the fiber is so important, all the aspects that you mentioned, it helps in digestion, it helps promote the healthy probiotics because it is a prebiotic which feeds the probiotic good bacteria in your gut. It helps move things along and also creates an osmotic gradient where pulls water into the intraluminal space so that you're not developing these hard rock kind of products that can create diverticular disease and it can lower your cholesterol by helping you eliminate waste more efficiently. Some studies can even suggest that it can lower your risk of cancer. So all the good reasons to take more. But again, the biggest thing that I run into is people grossly underestimate.

I mean, they think they're taking in X amount of fiber, but in fact when you do the math accurately with a dietician, they actually find out it's grossly overestimated. So you want to take more. You also want to take good high quality fiber as well. So the fibers that they think they're getting in a tiny little gummy is really not going to be as high in quality as you get from the natural foods that you just mentioned. Additionally, even nuts, a lot of patients don't know like almonds have a lot of fiber and they may not have connected that together as a possible potential source of fiber. So all of that education is important. It's very key to success for our patients. And then there's a growing percentage of population that are very health conscientious. So they're doing a high protein diet, they're on the protein powder protein shake, which is fine because they meanwhile, but understand when you're doing these high protein diets that you have to increase your fiber intake because protein, although as healthy as it is for you, it is very constipating for your intestines. So you really do need to offset that before you get into the realization that you're in trouble, meaning constipated. You want to be proactive and make sure you're taking that high protein shake with plenty of water, make sure you're not dehydrated and you're interspersing those shakes or protein intake with high quality fiber in between them.

John Horton:

Dr. Lee, we've been talking a lot about how you can kind of just cause a bunch of problems with that microbiome. Lemme ask you this. I know you have tools where you can go in there and actually look at things. What does a depleted microbiome look like?

Christine Lee:

So that's hard to say from an imaging standpoint. So microbiome's microscopic level. So you won't be able to see that from a CT scan or an X-ray. You really won't see that on an endoscopy either, whether you've had a colonoscopy or an upper endoscopy. We can only see the structure, the structure of or the anatomy of the small intestines or the large intestines. So if we see severe diverticular disease, meaning diverticulosis all over the place or your colon is really distended twice the width and twice the height that it should be, and you look at the walls and the walls look very droopy, meaning they've lost that elastic recoil, it's wrinkly because it's been stretched at some point for so long that when it's not stretched or you did eliminate by taking a colonoscopy bowel prep, it kind of collapses. So we can see the aftermath of, but we can't see a direct the microbiome through an imaging study per se.

John Horton:

Alright, so not the microbiome itself, but you're seeing the results of it being off its game I guess with everything being just a little ickier down there.

Christine Lee:

Absolutely. Yeah. The suggestive effects that it might've had on the digestive tract.

John Horton:

So now you mentioned diverticulosis and some things like that. Let's get into a little bit about what happens when your gut microbiome is off its game.

Christine Lee:

Well, when it's off its game. You had mentioned diverticulosis, that's not, the microbiome isn't the only culprit for producing diseases like diverticular disease. It can be one of the culprits but not the only ones. I think that's important to lay out. But when your microbiome is off, then your intestinal tract system meaning the Circadian rhythm is off. So how it processes digestion, meaning it may take you twice as longer in the stomach to pass onto the small bowel and the transit time from the small bowel to the colon could be twice as long or at least prolonged. And while that's happening, one may feel sluggish, full early satiety or not hungry or even nauseated. So a lot of the symptoms can vary from person to person, how it manifests in one person versus another. But overall it decreases efficiency. You might be missing out on some of the healthy nutrients that you consumed in a healthy diet because you weren't able to break it all down and have an opportunity to absorb it. So it affects people very differently. So it's important to kind of tease out case to case again, I don't want to say microbiome's, the only reason that people suffer from diverticular disease, but it can be one of the culprits.

John Horton:

Yeah, it sounds like it's a contributing factor a lot of times.

Christine Lee:

Yeah, absolutely.

Julia Zumpano:

So John, I want to mention a couple of the foods that can definitely decrease the healthy gut bacteria and promote growth of bad bacteria. So Dr. Lee beautifully explained some of those already, but those hyper processed foods, those packaged foods and foods that are high in sugar, alcohol, refined, refined grains, bakery items, all of those things that really have no fiber, have a lot of artificial ingredients, sugar, alcohol or heavy fats like saturated or trans fats, those can really wreak havoc on our gut. They can definitely decrease the good bacteria because you have no fiber to allow them to grow and then they can help promote the bad bacteria to grow. They will further exacerbate symptoms of reflux and constipation and can even lead to other symptoms like stomach pain, abdominal pain, or bloating. So we really want to clean up the diet of some of those foods that can inhibit some of those negative GI symptoms and support the gut with all of those plant-based fibrous foods.

John Horton:

Actually, Julie, we are actually going to dive right into a lot of the food products that we should and should not be eating because from the sounds of all these gut issues, we want to avoid them. So we've thrown a lot of 'em out here and there throughout, but let's kind of just really zero in on some of the things that we should definitely be adding to our diet in order to promote better gut health.

Julia Zumpano:

Great question. So we briefly talked about protein. Dr. Lee said it beautifully, if you're on a high protein diet, you could be lacking enough fiber. So I think it's great to focus on protein, but couple it with a fibrous food. So for instance, if you're making a protein shake, I always recommend throwing some greens in a protein shake and maybe some fruit, some chia seeds and flax seeds. So I pack that protein drink with a ton of fiber, so you could easily pack 10 to 15 grams of fiber in. Think about ways you can squeeze in fiber in your day all throughout the day. You have to be heavily focused. So avocados are high in fiber. They can be great added to almost any breakfast. We have greens that can be fresh or frozen. You can throw them in, like I said, shakes or smoothies, throwing over protein over any type of bed of greens.

Beans are a great source of protein. There's a lot of phenomenal bean based pastas out now that are a great way to get beans and get fiber and decreased carbon intake. Bean based pastas also have a tremendous amount of protein, not to mention the fiber of course. So you're really serving both dietary and macronutrient needs. Other ways, of course, fruit. So I do encourage fruit as snacks or as supplements to meals. I think we get in the habit of eating sweets on a regular basis, and I think fruit can be nature's great sweet alternative. So fruit is very abundant in fiber. Some fruits more than others, but we know apples and pears have that soluble fiber. Berries are phenomenal for soluble fiber. Grains like oats and quinoa have a tremendous amount of soluble fiber as well. Soluble fiber is water soluble. So water gets absorbed in that fiber and forms like a gel or a gum.

And that gel or gum is very important because it softens stool and it's what binds around bile in our guts. And as Dr. Lee mentioned, bile is waste that is composed of cholesterol and it eliminates that waste, which therefore lowers cholesterol essential for overall heart health. One key though is liquid. We need enough water. If you are going to increase your fiber intake, you have to have more water, otherwise you can become constipated, as odd as that may seem. So water softens that stool. A lot of these foods pull water into the gut and we want that water to be pulled in and to soften and absorb those soluble fibers to create a nice form stool. And that's not difficult. Very easy to pass. So we really want to focus on plant-based foods. Dr. Lee also mentioned nuts. Nuts are a great source of fiber, so any kind of nuts are great.

Almonds, walnuts, seeds are phenomenal. Chia seeds and ground flax seeds are wonderful sources of dietary fiber. I add those into almost every single patient I see. I recommend added chia seeds and ground flax seeds because they're so abundant in fiber, they're abundant in protein. Omega threes, they're an easy way to add into things like sprinkling on top of the salad and some oatmeal and a smoothie. So a lot of ways that you can think of what you're already eating and how can we add a little fiber to that meal and that snack every time you eat, you want to look at your plate and say, what on this plate is a good source of fiber?

John Horton:

Earlier we had mentioned probiotics and prebiotics, and those are two things that sound very, very similar, but there is a big difference between them. Can you break down what each one does?

Julia Zumpano:

Yeah. So a prebiotic is fiber. It's essentially a vegetable or bean or grain that has this prebiotic, which is a fiber, it's called a prebiotic fiber. They're also found in supplements, which you can take a supplement of a prebiotic fiber, but of course we want to get it through food. And then the probiotic is that those good gut bacteria, so the good G bacteria are called those probiotics and they're found in foods like kimchi and keefer and fermented foods. So you can find probiotics and things like -

John Horton:

Yogurt too, right? I mean those are the live cultures in yogurt that you always look at and what is in here that's living right?

Julia Zumpano:

And it's healthy bacteria. So those are those probiotics that when you ingest them and they go into your gut, they grow, they flourish. The more fiber you feed them, they will flourish even more. And that's what we want to do is have those probiotic, those good gut bacteria flourish by feeding them more of the prebiotics.

John Horton:

Okay, that's what I was going to say. Probiotics are kind of bringing more of the good bacteria in, and prebiotics is kind of making all that good bacteria that's already in your gut a little healthier. It kind of feeds it.

Julia Zumpano:

It's helping them grow.

Christine Lee:

Simply put, you can consider probiotics as a good gut bacteria you need for digestion and prebiotic is the food that the probiotics need to grow and reproduce and flourish perfectly.

John Horton:

Yeah. Now you had mentioned the foods that just aren't good for our gut and that microbiome. What are some of the things that we need to look at avoiding or minimizing as we go about nibbling through the deck?

Julia Zumpano:

So of course we want to limit refined grains, so white-based carbohydrates, white bread, white pasta, white rice. That doesn't mean we can never eat anything like that. We just want to minimize those things. Really encourage the whole grains as often as possible. Very sugary foods. So sweetss and desserts and bakery items. Artificial sweeteners can also affect the gut microbiome. So that's one of the most common things I see my patients consume is artificially sweetened drinks. And not only are they not good for your overall health, but they do really wreak havoc on your gut microbiome. Alcohol can affect your gut microbiome. So those are the things that we really want to minimize. It's okay to have some alcohol here and there, some artificial sweetener here and there, but we want to look at how often are we consuming these foods, how frequent, what volume we're taking it in at. So we really want to minimize anything that's going to inhibit the growth of a healthy microbiome.

John Horton:

And we've been talking about food, but I think we should also add in here that lifestyle factors also come into play. So things like exercise, stress, sleep, I'd imagine all of those play a key role in what's happening there too.

Christine Lee:

If you are sleep deprived or your sleep cycle is thrown off, it really throws your circadian rhythm off. And so your natural hormones that help move things along and how you have your endorphins, those hormones that help give you energy and help you concentrate and help promote motility are all thrown out of whack if you're sleep deprived. Additionally, if you have a sit down job, office work or executive work and you're eight, nine hours a day, you have to be sitting. You actually decrease blood circulation and perfusion to your pelvic area when you're sitting because your entire body weight is on one focal point, and so it does decrease circulation there. So it really puts you at risk for constipation and travel. No one thinks about this because during traveling, most people are stressed about missing their flight or catching their cab on time so they're not in tune to their body.

But whenever you travel, everything kind of gets sucked in and held onto until you get to the destination site where everything then relaxes. So nothing constipates you more than travel, which is oftentimes overlooked. People always say, Hey, whenever I travel, I get bloated. I feel terrible, I get diarrhea or I get nausea. Well, everything's been kind of locked up and held onto, and it's a set up for bacteria overgrowth, so it can really upset your system. So sedentary lifestyle, whether it's because you have a sit down job or frequent travels or long commutes are often overlooked as exacerbating factors to your gut health. And then we did talk about antibiotics. Not to say you can't take antibiotics if you have an infection, you got to get treated, but know that that puts you at risk for killing the good bacteria too. So you really want to delve into what Julia had mentioned of all the healthy foods, the high value items. A cookie may be good for your craving, but doesn't carry the natural nutrients and the abundance of fiber that one actually needs when you are post-antibiotic or whatnot where you're trying to replete your gut flora. So you want to eat the high ticket items, food that gets the biggest bang for your buck. So the cabbages, the quinoa or the chia seeds, those foods carry a lot of prebiotics, some foods that have probiotics. You want to indulge in those kind of foods to help your gut system out.

John Horton:

Help it get back to where it needs to be.

Christine Lee:

Yes. And then nowadays people are living longer and it's not uncommon that one has gone through multiple surgeries, whether they've had a knee replacement or a hip replacement or both hip replaced. Those are very painful orthopedic procedures. So one that has little room for post-op infection. So oftentimes unbeknownst to the patient, they might've gotten powerful IV antibiotics intraoperatively to prevent an infection. So you want to make sure that you are combating these insults to your microbiome. And then when you do have a painful orthopedic surgery, they're pretty sedentary during the immediate post-op days for recovery purposes, obviously. But it's very common to have post-op constipation, and oftentimes people don't even know it because they're taking pain medicine for that hip surgery. So if they're taking pain meds so that they don't feel the hip pain, then they're not going to have the constipation signals that's not going to come in or get registered as well. So don't wait until you have alarm symptoms firing, be proactive and make sure that you're eating all the healthy foods that Juliet mentioned. Those are excellent advice. I couldn't have said it better myself. I wish I could tape record her and replay it over and over again because it's so helpful and it can prevent so many things that patients suffer from, whether it's burping, heartburn, dyspepsia, irritable bowel, diverticulosis, diverticulitis, bowel obstructions, all of those things can be prevented if you're really proactive.

John Horton:

Well, this is why we have the podcast so they can back and listen to those words of wisdom whenever they need them.

Christine Lee:

So I am always surprised that we have to reinvent the wheel with every patient. So I am a strong advocate for these podcast opportunities because this is where we can get the word out in masses and so that we can do it all at once rather than reinvent the wheel individually.

John Horton:

As we've talked about here, the relationship between certain foods and your gut can be incredibly complicated. And what really drove that home for me was reading about, I guess the low FODMAP diet diet. And I know that's a very restricted eating plan for people who have certain GI disorders like IBS, but the concept in general just really shows that certain foods can trigger issues downstairs.

Julia Zumpano:

I would agree with that, John. I mean, the low FODMAP diet takes certain fermentable carbohydrates that ferment in our gut and can create symptoms, and certain people may have sensitivities to some of these fermentable carbohydrates, and the low FODMAP diet eliminates some of these fermentable carbohydrates or most of them to see if it can really resolve some of the symptoms. So essentially this is a form of an elimination diet. So we do as dieticians, we will guide someone through an elimination diet, whether it be a FODMAP or dairy or gluten or whatever may be triggering some of your GI symptoms. But in the end, really what's most important is to cut out the junky food, increase the fibrous foods and see if the symptoms go away first before you're eliminating food groups. As a dietician, I am trying to add food to people's diet, not take away, my goal is to flourish people's nutrition, not start to remove all of these healthy foods because some of these fermentable carbohydrates, most of them are plant-based foods and they're extremely healthy for the body.

So in some cases, a low fmap diet can be very beneficial to decrease symptoms, but that should only be followed in a short period of time for purposes of an elimination diet. So really meeting with a registered dietician to walk you through the process of a low fmap diet, the elimination diet, and properly adding the foods back in within a month because if you follow it longer than that, you risk the chance of having multiple nutritional deficiencies, and that's not where we want to go. We want to improve health, not start to decrease the quality of health here. So I think it's very important if you feel that there are certain dietary triggers to work with a dietician or even follow your own slight elimination diet, you think dairy triggers something, cut it out for a week or two, you notice your symptoms decrease, great. You're probably sensitive to dairy. Find out, add small servings of dairy back in very small portions and see what your threshold is. Everyone, most people have a little threshold or find if there is a specific dairy trigger, is it all of it? So you can do small experiments on your own, but our goal is really to minimize what we're removing and more adding whole foods.

John Horton:

I was going to ask how many of these food related GI issues are personal and just specific to each individual?

Christine Lee:

Not all irritable bowel syndrome patients are the same. You don't want to impose what works for one patient on another person. They're uniquely different. So it's important to kind of sit down one-on-one and find out what your triggers are, and more importantly, why are those your triggers? So I really love the fact that Julia said she really works on adding food to the patients rather than taking away. So when they're suffering, you do need to seek help from the expert like Julia, who can guide them through their symptom relief with a temporizing FOD mat restricted diet so that they can temporarily not feel so much discomfort during that period of time. But in that time, you need to make sure you find out why are those your triggers? Why can't you tolerate fermentable foods like everyone else? Once you get to the why, then you can fix that.

Then eventually Julia can help you put that back into your diet. So I'm all about that. It breaks my heart when I see people are on such a restrictive diet for an infinite amount of time because that doesn't cure you of anything. It just tells you to avoid that for the rest of your life. You don't really want that. You want to know why is that your trigger? Why can't you tolerate that particular fermentable food when someone else can? Once you get to the why, then you can get to the solution and then she can help you add that back into your diet so that you don't miss out on that nutrients or nutritious food. So you can have variety back into your life, but until that happens, you are going to need the expert assistance from dietician to help you guide through your gluten-free living or FODMAP restrictive diet during that period as you figure out the whys.

John Horton:

So Dr. Lee, I mean, building on that, when you first see a patient who's dealing with GI issues, how much of a focus do you put on diet while trying to find a cause or even a solution?

Christine Lee:

Yeah, my focus is on the patient. I let them talk all times. You'll be shocked how much information you can glean. The patient actually has all the information there. They may not know which one's important and which one's irrelevant, which one's very relevant. So you just let them talk. If they tell you their history, they will pretty much tell you their story, meaning the diagnosis can be narrowed greatly just by listening to them. They'll oftentimes give you a pattern or history, meaning they might latch onto the last food that caused the flare or the vout, but we're focused on, huh, you're focused on the food trigger, but it seems like this happened right after a trip or whenever you had a stressful event like a divorce or a loss of family member. So every information's important. You just need to get it out of them. And a lot of times they will offer that if you don't interrupt them. So you just need to get the information in a way that they perceive it and then guide them through is what's the relevant part, and then focus on what we call the differential with that information.

John Horton:

Is adding a registered dietician, like Julia, just kind of a standard part of the process as people work through these issues?

Christine Lee:

They're absolutely vital. Multi-discipline approaches the key success. This is not a one man shop. So if we have the luxury at the clinic, we're very blessed that we have a robust nutrition team or dietician team, colleagues to work with. So we're very fortunate in the setting that we practice. I'm not sure that I can say that it's standard of care because all parts of the United States, there are some areas where they're in shortages, so they don't have the luxury of a licensed dietician or the experts to help. And so unfortunately they work with what they have. But here at the clinic, we're very fortunate to have a robust department with experts such as Julia, and the multidisciplinary approaches always help promotes a high test rate, and it gives patients more information, a much more detailed sophistication that I can provide as far as individual foods and what foods are really high impact foods and what are less impact foods.

John Horton:

Alright, well Julia, now we're going to put you on the spot. So Dr. Lee, seen her patient and said, you need to go talk to a fabulous registered dietician such as yourself. What do you do when people first come to see you? What's the process that you go through?

Julia Zumpano:

Great question. I do what Dr. Lee says. I let the patient talk. I ask a lot of questions, but then let them talk. So I ask a lot of questions about what they eat, what their symptoms are, what their activity is, when their symptoms occur, what issues could trigger some of those symptoms. So we take a full assessment, it's not just about diet. We take a full assessment, including I ask about sleep, I ask about stress. So I really look at the full picture because remember, we're looking for the root cause here. We're not just trying to just fix it or put a bandaid on. We're hoping to discover this root cause so they can truly be healed and live a life of health. That's really our goal. So I step go through multiple steps to determine what I think could be some triggers, whether it be food or stress or lifestyle, and then I try to come up with some solutions with the patient. Of course, we work together in coming up with some solutions on some of their issues and problems. So it's a very holistic approach. I take a lot of things into consideration and I really do involve the patient in the plan because that's essential.

John Horton:

Okay, so now the really big question, if a person changes their diet, can they fix some of the gut issues that we've been talking about today?

Christine Lee:

They can definitely improve their gut health. I don't know that they can go back to perfectly being normal. As we get older, there's always wear and tear in our system, and so we can always work on delaying the aging process or delaying the slowing down process and we can always work on improving our current status. But unfortunately we haven't found the fountain of youth yet.

John Horton:

I keep hoping one of these times we're going to have a podcast and that's going to come out that you guys have cracked that code, but not today, huh?

Christine Lee:

Well, I'm still waiting for Julia to tell me the magic fruit that'll turn me back into my twenties.

Julia Zumpano:

I'm still waiting for that too, Dr. Lee.

Christine Lee:

But until then we can definitely improve our gut health, but we can't really reverse the clock.

John Horton:

I guess. Can people tame some of those symptoms? Obviously we've talked a lot of the things you brought up. There's a lot of discomfort and just it's not a good feeling. So if you do start eating more fruit and veggies and mixing in the legumes that you were talking about and the whole grains will create that healthier gut that will make some of those problems just really be minimal and then you can go about your day without having to worry about things kind of tumbling and going all tumbly turvy down there.

Christine Lee:

Absolutely. I've had the luxury of or the opportunity to practice at the clinic for over a decade now. So I've had followed patients over a decade of time and I might've met them when they were seeking help because they were having four or five episodes per month. And when we see them once a year initially and then now we see 'em every five years when we do the colonoscopy, their diverticular disease is not progressed. It's not back to normal obviously. It's always going to be where it was at, but the good news is it's not any worse than it was 10 years ago. And then when I talk to them, they're like, well, I barely have one episode a year now. And that one was having, wow, that's a big difference, five to seven a month and they couldn't get into our office fast enough and they wanted to be seen every three months, but now we see 'em once every five years.

And we can also tell from the bowel prep when they were having a lot of issues, they do the whole bowel prep just the way it's written. They did everything, but when you come to the endoscopy, they have to abort or they tell 'em the prep was suboptimal. They still had quite a bit of stool or colon and they're just crushed. But then now 10 years later, now they're 10 years older and you think it'd be harder to clean, but because their gut health is healthier and they're eating right, they took the same bowel prep that didn't work 10 years ago, but they're spic and span. I always joke with them, it's clean enough. You can have a picnic in there. And so sometimes just stopping the progression can be the goal, and that's really rewarding and satisfying.

John Horton:

I think that you've seen the same sort of positive effects.

Julia Zumpano:

Yeah, I would agree. I mean, we're really looking. We can definitely minimize symptoms, improve symptoms, come up with a plan when flareups, because they happen when flareups and bouts of uncomfortableness happen, the recovery of that is much quicker. We develop a plan on how to get that recovery quicker and that actual flareup be much less intense than normal. So overall, the whole picture just improves. And over time, if the diet continues to improve, because of course we don't expect anyone to change overnight, that's not the expectation. But as the diet continues to improve, the symptoms will continue to improve. The flareups and the bouts will continue to lessen and lengthen in time, meaning they're just not happening as often. So we definitely see positive changes as time goes on. One thing I think we fail dementia is the importance of exercise. We've touched base on how bad it is to be sedentary. That food, that food has nowhere to go. So movement helps move that gut moves that food around. So movement is one key component here to gut health. So whatever you can do, whether even if you're standing, do a standing desk, whatever you can do to move is going to of course support that gut motility.

Christine Lee:

I couldn't have said it better myself. Exercise is truly the best medicine on earth. It improves circulation and circulation is what you need to kind of keep things moving along. It kind of makes sure your muscles are being fed with good oxygenation and blood supply so that it can stay strong and healthy. It promotes motility, it promotes circulation itself. You want the movement. It takes all the bad stuff out on it. It gives all the good supply in exercise, hands down is the best medicine on earth.

Julia Zumpano:

Helps your mood too.

Christine Lee:

Provides more energy, supports organs health. It's most single handedly the most powerful medication that you can prescribe to a patient, unfortunately underutilized. So it is key to health, it's key to longevity, it's key to cure. So I would recommend exercise to everyone as much as you can. People always want to know well how much, what type? It really has to be patient dependent. If you have back disorders, you may have to do more of the chair yogas or wall Pilates. You have to find one that you're able to do and that you're able to stick with, but you want any kind of exercise that your body will allow you to do is highly recommended.

John Horton:

Yeah, I've said multiple times on this podcast. It's amazing. No matter what the problem is, exercising more, eating healthier, sleeping better, you do that, so many things go away.

Christine Lee:

Three key components that everyone needs to make sure that they do.

John Horton:

From everything that we've talked about and learned today, it sounds like a healthy gut leads to a happy gut and definitely a happier you. So before we say our goodbyes though, since I have both of you here, I want to just find out if there's any other tips or advice or things you'd like to add in regarding GI health and food choices.

Julia Zumpano:

Well, I just want to add that we've covered a lot and it can be overwhelming when you want to make a change. So start with one small change. Start with whether it's your tracking your fiber and you would eventually want to get to a goal of 25 grams a day, or you just want to add flax seeds or chia seeds to your diet or drink more water. Any change is a positive change. So just think of it in small movements, small positive goals, and then eventually build and build and build and you'll get to your optimal state, whatever that is for you. I think it's really important to not get overwhelmed because oftentimes spill can't get overwhelmed and then they're like, well, forget it. I can't do all this. Well, you just pick one thing and start there. Start small and then build, and I think you'll really be pleased with the outcome.

Christine Lee:

That's a great advice from a medical standpoint, patient always likes to ask, well, when should I see my doctor? No one knows your body better than you. And I always say, Hey, if something's not right, it's best to just have it checked out. When in doubt, check it out.

John Horton:

Perfect way to end. So I appreciate both of you coming in here and sharing so much of your knowledge.

Christine Lee:

Thanks for having us. Thanks, John.

John Horton:

An entire ecosystem exists in your gut and what you eat goes a long way toward determining how well it functions. A healthy diet is key to a healthy gut microbiome and a healthier you. If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic/he-podcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.