Dr. George Papanicolaou:
You need to be able to evacuate your toxins, your metabolic waste, and the more that stool sits there, there are biochemical changes that happen in that stool that allow for the toxins and the compounds that your body didn’t want anymore to leak back into your system.
Dr. Mark Hyman:
Welcome to The Doctor’s Farmacy. I’m Dr. Mark Hyman and that’s Farmacy with F-A-R-M-A-C-Y, a place for conversations that matter and welcome to this special episode called house call where we dive deep into health conditions through the lens of functional medicine. And I’m here today with my friend and colleague, Dr. George Papanicolau and we are going to get deep into the poop story, or more importantly, why people don’t poop, can’t poop have trouble pooping and how to fix this terrible problem. It affects millions and millions and millions and millions and millions and millions and millions of people called constipation. Not a fun topic to talk about, but unfortunately, it’s my favorite topic because it’s so easy to fix.
Dr. Mark Hyman:
And I just had this one patient who was so funny, I’m just going to quickly tell this story then we’ll jump right in, George. So I was like, “So do you have regular bowel movements?” She’s like, “Oh yes, I have regular bowel movements.” I said, “How often do you go?” She goes, “I go every week.” I said, “That’s not regular.” She goes, “It’s regular for me. I go every week.” And I’m like, “Whoa. So people have no idea what it’s to have normal bowel function. You should probably go two or three times a day.
Dr. Mark Hyman:
In modern industrial society, the average stool weight is four ounces. In hunter and gatherers who eat tons of plant foods and fiber, it’s two pounds, right, which is eight times the weight of somebody who’s not eating the right food. So I often hear from patients, “Dr. Hyman, I didn’t know that this was normal, that I could actually poop every day.” So we’re going to get into it. So welcome, George. So let’s talk about constipation. This is going to be a fun conversation.
Dr. George Papanicolaou:
I do have to say, when you were talking about the Hunter gatherer, I’ve had to say that the size of the toilet would have had to have been the size of the dinosaur.
Dr. Mark Hyman:
That’s right. Well, you see like elephants who ate hundreds of pounds of roughage and fiber every day, I think they poop like 50 kilos a day or something ridiculous. So tell us about how common is this and what is going on?
Dr. George Papanicolaou:
It’s a really common problem. The prevalence is very high so 80 million people are going to suffer with constipation and it gets worse as you get older. And it’s an $800 million business and that’s an underestimate because of the over the counter meds. So it’s only $800 million that’s being spent to have a nice bowel movement.
Dr. Mark Hyman:
What do you mean? You mean with doctors, you’re not talking about the stuff you get over the counter like Ex-Lax and Senokot.
Dr. George Papanicolaou:
No, no, no, that’s with doctors and I said it’s an underestimate because it doesn’t include the OTC meds
Dr. Mark Hyman:
The over the counter meds you get in the groceries which is probably way more than that, right?
Dr. George Papanicolaou:
Mm-hmm (affirmative).
Dr. Mark Hyman:
So tell us, one, what are the complications of constipation? And why is it bad to not go regularly? Why is constipation bad?
Dr. George Papanicolaou:
Yeah. So first off, what is not regular and what do people consider constipation and why is it something that people are [inaudible 00:03:32] up? We see people with gut issues and constipation. Almost one out of every three patients of mine, no matter what they’re coming for has a gut issue. So gut issues in general are just prevalent throughout the world, quite honestly, because we get people from all over the world in our center. So I’m always dealing with gut issues, particularly constipation. Constipation leads to bloating and distension and then people identify foods that cause the constipation. Then there’s food fear and anxiety, and it just begins to really take a toll on people’s lives. And so it is a really big deal.
Dr. George Papanicolaou:
What’s a normal number of bowel movements? Now I was taught anywhere from three bowel movements a day to one bowel movement every three to five days.
Dr. Mark Hyman:
Hah, no.
Dr. George Papanicolaou:
Yeah. That’s what I was told a long time ago, but the most recent study using the most respected tool for studying, it’s called the room three, identified constipation as less than three bowel movements a week. So in conventional medicine that’s what it’s defined as, less than three bowel movements a week for more than three months.
Dr. Mark Hyman:
So when you get constipated, it causes other health issues. So why is it bad to be constipated? Okay. So I go three times a week, I go, it’s pretty regularly. Why care?
Dr. George Papanicolaou:
Okay. I think there’s two ways to look at that. One is that not once I’m constipated with the problems, but what got me to being constipated in the first place? And that goes back to what we always talk about is how you live, it goes back to lifestyle, it goes back to nutrition, it goes back to stress, it goes back to exercise. And just to name three of the lifestyles that are most impactful. So if you’re not getting good exercise, you’re not getting good sleep, you’re not eating nutritious, you’re going to be in a position to end up with gut issues including constipation. So how you got there is really important because if you’ve gotten constipation, that’s just the beginning of the problems.
Dr. George Papanicolaou:
And then once you have the constipation is the problem is that you need to be able to evacuate your toxins, your metabolic waste. And the more is that stool sits, there are biochemical changes that happen in that school that allow for the toxins and the compounds that your body didn’t want anymore to leak back into your system. And when that happens, then you begin to impact your immune system, begin to increase inflammation. And as we always talk about, that inflammation begins to impact every organ system in your body.
Dr. Mark Hyman:
Okay. So bringing it down, there’s really two main issues. One is just the direct harm from being constipated which includes hemorrhoids, anal fissures, anal prolapse, pain, and also just feeling like crap because you’re full of crap. You’re full of crap. And you’re literally reabsorbing a lot of the toxins that get excreted by your liver right into your intestinal tract. You’re reabsorbing them. You’re also affecting your hormonal metabolism and you’re producing all these products in there that are getting absorbed.
Dr. Mark Hyman:
And what’s true about your gut is it’s a whole ecosystem of bugs in there that has to be healthy. It’s like a garden. And if the garden isn’t healthy, you’re not healthy. Your immune system is disrupted, you’re toxic. It creates brain inflammation. It creates systemic disease, heart disease, cancer, diabetes, Parkinson’s, I mean, Parkinson’s disease. You’re 400% more likely to have Parkinson’s disease if you’re constipated, and we know that Parkinson’s disease is related to environmental toxins. So not only are you having this sort of anal and physical issues of being constipated, not only do you feel like crap, but it has long-term risk for many, many chronic diseases.
Dr. Mark Hyman:
So it’s really important to go and go often. And go every day or two or three times a day. And once you understand how to regulate your gut and fix the causes of constipation, then you won’t be constipated, and most doctors just give you laxatives or tell you to have more Metamucil or fiber. That can be helpful, or drink a lot of water, but there’s so much more to it. So tell us what is the conventional medicine approach to constipation? And then let’s talk about the functional medicine approaches to constipation.
Dr. George Papanicolaou:
In conventional medicine, again, it is the name it blame it symptom and treat it. And so they treat the constipation. And so over the counter, you can get all types of different products that will be either they’ll be bulking agents. You can have laxatives that bring more water into your stool, you can have lubricating agents. All of these are available. All they do is get the poop out and make you feel more comfortable, but it doesn’t solve the underlying problem. And then for people with what’s called chronic idiopathic constipation, which is the most common, idiopathic means by the way, I don’t know. Right? So I don’t know why you have it, but I’m going to give you a really expensive drug to make your bowels move. And so there are really expensive drugs on the market that stimulate the receptors in the bowel to get them to move so you can have a bowel movement.
Dr. George Papanicolaou:
So that’s the conventional approach. Let’s get it out and let’s make the bowels move faster so that it will come out. But we’re not going to look at the underlying root causes of why the person’s constipated and nor are we going to think about the downstream effects of that constipation, not only of the constipation itself, but to get to that constipation, again, it goes back to the fact that it’s this long term inadequacy of your diet, the longterm impact of stress that results in constipation. But what you can’t see is the impact it’s having on your brain, the impact it’s having on the blood vessels of your heart, the impact it’s having on your immune system.
Dr. George Papanicolaou:
So on the functional medicine side, that’s what we do. We begin to focus on nutrition, stress, lifestyle, exercise. We begin to be changed people’s lives so that they’re living healthier and therefore the constipation can resolve on itself, now as you said that-
Dr. Mark Hyman:
Yeah. Well, before you jump into that, I want to talk a little bit about the problems with traditional treatments because yes, it’s fine to take extra fiber and so forth, all times I have weird artificial sweeteners in it and stuff that’s weird. You can take mineral oil, which is fine, but that’s kind of gross. You can take various laxatives and some positories. A lot of the treatments can be very dangerous like Ex-Lax or Senokot or Cascara. Things that are even considered natural because they create a lazy bowel. So people who’ve been constipating a long time, they take these drugs, which work for their body and even smooth move tea, which is fine for an occasional issue, but these things become habit forming and they cause a lazy bowel and people can get something called mega colon where they literally cannot eliminate without these things.
Dr. George Papanicolaou:
Absolutely.
Dr. Mark Hyman:
Or people get reliant on enemas or they get reliant on colonics. And the truth is unless you dig down into the root causes of constipation with a functional medicine lens, all these things are just like band-aids and they often are harmful, not helpful. So now let’s look down from a functional medicine perspective, how do you identify what’s causing a person’s constipation? What are the tests you do? How do you think about it? What are the main causes of constipation in our patient population?
Dr. George Papanicolaou:
Yeah. So the main causes of constipation are going to be one, I would say there’s food sensitivities. So not being aware of food sensitivities, and that can create inflammation and alter the function of your gut. There’s going to be nutritional issues like you’re just not getting enough fiber. I know you talk about using lodges fiber to treat the constipation, but you don’t get into that situation if you’re eating foods that aren’t processed or the processed foods that we eat don’t have any of the indigestible fiber that’s required for the stool to form correctly and also to maintain the healthy gut microbiome. So again, it goes down to nutrition’s involved and what else would be some causes?
Dr. Mark Hyman:
I think there’s a lot of causes. Let’s, just go through them. So you’ve got, you’ve got things that are often missed like thyroid, right? And you’ve got low thyroid function is a big cause. Lack of magnesium, which is a huge issue for people. I think 40% of the population is low in magnesium and that can drive constipation. People often have yeast issues from taking lots of antibiotics, which can be a big factor in constipation that causes dysbiosis. Dairy is the number one cause of constipation in kids and not only constipation, but anemia because the dairy irritates than guts in these kids and causes blood loss in the stool. So constipation from dairy is a huge factor.
Dr. Mark Hyman:
So we’ve got a lot of things we think about. It can be also things heavy metals, which are factors that can impair gut function or even weird things like tick infections could cause a neurologic problem in the gut that help damage the neurological pathways that cause peristalsis and that leads to constipation from tick infections. So from a functional medicine perspective, we really dive deep into figuring out what’s going on, and the treatment is often so easy and so effective. And we may start with the foundational things, right. We start with diet and then so we go on to the use of specific supplements and other things that can help fix it.
Dr. Mark Hyman:
So take us through this patient you had. And then let’s dive deep into the story of what are the real treatments that we find so successful in rebuilding someone’s gut so they have healthy bowel movements and have health as a consequence.
Dr. George Papanicolaou:
So the patient that I had, she was a 19 year old nursing students who came to see me and she had constipation after prolonged use of antibiotics, recurrent urinary tract infections. So interestingly enough, at the end of her first year of nursing school, lots of enormous stress. She had the past to be able to continue to nursing programs, she was in a new relationship and her diet was really not very good. She was under a lot of stress, she was eating poorly. So when she came to see me, she had significant constipation. And we do some tests that really help us get down to the root problem, and we do that complete diagnostic stool analysis that allows us to look at the microbiome. So we’re able to see if you have a balance of good and bad bacteria, we’re able to see if you picked up any bad guys along the way like parasites and worms that can impact your gut function. And we looked to see if you have all of the, the markers for healthy digestion, which is really key.
Dr. George Papanicolaou:
So we’re able to see if you’re making enough of the pancreatic enzymes you need, is your gut detoxification working correctly? Is your gut immune system working correctly, or markers is inflammation high? That gives us a complete picture of what’s going on in your gut. We also look for something called leaky gut, that when you have enough inflammation, you have enough destruction of the mucosal membrane, you’ll end up breaking down those gates that are responsible for keeping the bad guys out, letting good guys in. They’re called tight junctions. And when those aren’t operating, then bacteria and compounds and toxins can get into your system and trigger lots of inflammation and disease. So we do those tests.
Dr. George Papanicolaou:
We look for food sensitivities, the most common ones that we look for are going to be gluten, gluten cross-reactive foods that will include egg and dairy and soy and rice, because they will act like gluten in your gut when you’re sensitive to. And those will be produced when you have leaky gut. So I did all those tests on her and did I do any other tests on her? I just have to remind myself. Those were the tests that I did. And so what we told her-
Dr. Mark Hyman:
You look for spectral overgrowth, you look at the stool, food sensitivity testing, right?
Dr. George Papanicolaou:
Yeah. We did all that testing. And so what I found with her is that she did have significant leaky gut and she had something that’s called seatbelt. She has the bacteria that lives in your large intestine, it should just live there, and migrated up into her small intestine. And now it’s where we don’t want it to be. All that digestion and fermentation should happen in the large intestine, has very thick walls, and now it can maintain all that fermentation without you experiencing discomfort. But when you’re doing fermentation in the small intestine that has thinner walls, that fermentation starts to happen, the gases build up, you get bloated and extend it.
Dr. George Papanicolaou:
And if the bacteria that’s causing that overgrowth happens to be in the [inaudible 00:18:07] back and produces methane, those organisms, they will slow down gut transit, and that will lead to constipation. And oftentimes those people get labeled irritable bowel syndrome with constipation, and the conventional medicine will be put on medications like [inaudible 00:18:26] which will get the bowels to move, but not follow the problem which is bacteria in the small intestine. So in her case, we treated her small intestinal bacterial overgrowth with herbal antibacterials. We treated her leaky gut by using something called L-glutamine which supplies, nutrients for the gut to heal. I use [Casitone 00:18:51] as well because Casitone could actually impact and regulate the tight junctions we talked about and begin to heal the leaky gut.
Dr. George Papanicolaou:
So we took care of her leaky gut, we reestablished a good gut microbiome, and then we helped her understand the importance of her nutrition. So then I talked to her about getting more of the high fiber foods that she needs to get into her diet nuts, seeds, beans, chickpeas, chicory, dandelion root onion, garlic, which she can’t get right away. We had to increase her fiber after her SIBO was treated because some of those foods will actually exacerbate her symptoms. But once we treated her SIBO, once we took care of dysbiosis, and then we talked to her about the lifestyle changes that she could make, which included higher fiber with the foods, I just mentioned, which included, making sure he did drink enough water, because water is important.
Dr. George Papanicolaou:
You need that water in the stool to make it fluffy and move quickly and easily through the gut and finally out through the rectum. If you get hard stools, they are really uncomfortable. And lots of times people call constipation hard stools. I could have hard stools. I have them every day but they’re hard, and that is constipation to some degree and it’s uncomfortable and painful, but that is because they’re just not drinking enough fluid, they’re not getting enough fiber. Now, going back to the neanderthal man, his poops are really big cause he was getting 150 grams of fiber a day. Today, less than 5% of the American public gets the amount of fiber they should, which is anywhere from 20 to 40 grams of fiber.
Dr. George Papanicolaou:
Most people are getting about eight to 10 grams fiber per day. And that has a lot to do with why we’re having gut problems, dysbiosis, because that fiber also, when it’s broken down, produces a lot of nutrients that are good for the colonocytes and good for the healthy bacteria so that they can maintain a good robust population. So we fixed those things in her and her constipation was gone within six weeks.
Dr. Mark Hyman:
Yeah, it’s pretty amazing and I see this to of my practice, George, and we really take a comprehensive approach. It’s the obvious things, right? Eat lots of fruits and vegetables, nuts and seeds, high fiber plant rich foods, drink lots of water, get exercise. All those things really help. Medications are a huge factor sometimes. Iron supplements, blood pressure supplements, narcotics, diuretics. These are common medications. They will cause constipation, you have to work around them. Make sure you check your thyroid, make sure you check for diabetes because that can affect the neurological system. Heavy metals can be a factor. Even tick infections we talked about and even things the dysbiosis and yeast from eating all the antibiotics and processed foods.
Dr. Mark Hyman:
So all these things we want to think about. And then often, in terms of supplements, there’s some really simple things to do. Magnesium is a big factor. I had a patient who was literally going every week. She had terrible migraines. She had all these other magnesium deficiency symptoms, muscle cramps, insomnia, anxiety, palpitations, and I gave what was equivalent of about 2000 milligrams of magnesium because that’s what she needed in order to actually get her poop. And the more time she needed less and less. We gave her probiotics, we gave her extra vitamin C which will help you poop.
Dr. Mark Hyman:
We can use things like fats. Fats are so great, they’re a lubricant. MCT oil, which is basically derived from coconut, we often joke and say that causes disaster pants because if you take too much of it, it’ll make you poop. That’s a good thing. So we really need to understand how to rebuild our whole gut using a comprehensive approach, looking for the causes and obviously getting rid of all the crap that makes you constipated. So that plus exercise, stress reduction is a comprehensive approach. And I can tell you there isn’t there isn’t a single patient. I haven’t helped poop every day over 30 years.
Dr. George Papanicolaou:
Yeah. I will tell you it’s one of the most fulfilling things that I treat because I can get it better and do it frequently. And really, I know when I’m helping somebody’s gut get healthier, I am helping them prevent significant disease down the road because the healthy gut, as Hypocrity has said death begins in the gut. And because longterm negligence in your nutrition and your lifestyle is going to lead to an unhealthy gut and the inability for you to get rid of toxins and to absorb the nutrients that you need to keep you healthy.
Dr. Mark Hyman:
Yeah. That’s right, George. And this is a very important point I want to emphasize in functional medicine, it’s not just about treating your symptom of constipation, it’s understanding how it connects to everything that can go wrong with your health. So being constipated is not just annoying or uncomfortable or pain, but it’s actually something that’s setting you up for really poor health outcomes across a spectrum of disease, whether it’s heart disease, cancer. I mean, if you’re constipated, you’re more likely to get cancer of the colon, for example. So it’s really important to get your gut healthy and we’ve done many podcasts on the gut.
Dr. Mark Hyman:
This is another one that focuses specifically on constipation, but I feel using a functional medicine perspective, using the kinds of thinking we use in functional medicine here at the UltraWellness Center, using the diagnostic tests that we do which are quite different than traditional medicine, we look at bacterial overgrowth, we look at stool testing, we look at nutritional testing, we can really figure out what’s going on with people and help them when no one. else can.
Dr. Mark Hyman:
And we’re now doing stuff on Zoom, it’s really awesome and we can preview it from all over the world. And it’s really fulfilling because we can really help so many people who just don’t get help anywhere else. And my goal is really to end needless suffering for millions of people through the power of functional medicine and it works and it really does work. And I think that the work we do here is just so gratifying for all of us who work there and I think our patients are so happy, and I’m really glad to be able to share some of the knowledge of stuff we’re doing with all of you, because I just want people to know that there is an answer often for something that’s causing you suffering that you might not be hearing about at your traditional doctor.
Dr. Mark Hyman:
So I really am excited for you, George, that you’ve given us this deep dive into poop. And I’m excited for the next podcast with you. Right now, this is more important than ever to regulate your gut and immune system because they’re connected in time of COVID, we really want to double down in getting our gut healthy and fixing our gut.
Dr. George Papanicolaou:
Am I getting a ticket to Hawaii for the next podcast?
Dr. Mark Hyman:
No. You’re not getting a ticket to Hawaii. But I’ll show you the beach if you want. So thank you, George, for joining us on The Doctor’s Farmacy once again, it’s been great having you. If you love this podcast, please share with your friends and family on social media, leave a comment. Tell us how you’ve dealt with your constipation, maybe we’ll learn something from you. Subscribe wherever you get your podcasts and we’ll see you next time on The Doctor’s Pharmacy. (singing)
