41. Will Bulsiewicz, MD, MSCI: Gut Health, Being Fiber Fueled & The Microbiome (Ep 16/17 Rebroadcast)

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. What is going on, everyone, and welcome to Medicine Redefined? What a year it has been. 2021 is coming to a close, and Medicine Redefined has been live now for a little over a year, and we have probably done over 40 episodes with a variety of guests in healthcare, touching on various topics, particularly topics in lifestyle medicine. And so with 2021 coming to a close, Altamash and I have decided to re-broadcast our most popular episodes. And to kick it off, we are going to re-broadcast episodes 16 and 17, and those were with Dr. Will Bulsowitch, also known as Dr. B, also known as the Gut Health MD on social media. Now, this is going to be all about gut health, and if you're new to the channel here, welcome, and you are going to learn so much in these next two hours. And if you've already heard Dr. B speak on our podcast, well, it never hurts to optimize your gut, especially with 2022 coming up. So sit back, relax, and enjoy the show, and I will see you at the end. All right, guys, welcome back to another show of Medicine Redefined. Dr. B, what's going on, man? Hey, guys. Happy to be here. It's a pleasure to be on Medicine Redefined and to see what happens with you guys. It's great to hang out. Absolutely. We are, before we even get started, again, I want to thank you for your time. I know you're a busy guy, so for you to just designate a little bit of time to sit here and educate us and talk to us. I know it's going to be an exciting conversation. I know Dar's here is just chomping at the bed because he, maybe in a different life, would have definitely gone the route of GI, and so he's obsessed with gut health before we get into all that. I kind of want to start at the beginning. You went to medical school at Georgetown, right? That's right. I went to Georgetown. It's crazy to think about this because it's weird. As you start to age, I'm sure a couple of years older than you guys. As you start to age, you still feel like the same person. I still think I'm the guy from college, and it's crazy for me to think that I graduated med school 15 years ago, and it's like, wait, that number doesn't make sense to me. Absolutely. Time just flies. It even stemmed your inspiration to kind of go into medicine in the first place. What got you there? I was a teenager. I was a teenager. I was very much an idealistic type of person, so, you know, and I always wanted to do something where I could help people. So actually, I thought that when I was early in high school, I thought it was going to be a veterinarian, and I hated cats, though, like they terrified me. Oh, that breaks my mind. Yeah. The irony of all ironies is that now I've had cats for like the last 10 years. I haven't had dogs in more than 10 years. So the irony is I've come full circle on cats. I love them. They love me. We get along really well. But here I am in this career in medicine because I pivoted and I moved towards, okay, well, if I can't take care of cats, like if they scare me, then let me focus on taking care of people. And so I made that decision actually when I was in high school, and I went into college planning to be pre-med, and just kind of followed through on that. I was very focused, like super focused. I didn't join a fraternity, even though all my friends did. And just kind of like was kind of hardcore about the whole pre-med thing. I was at Vanderbilt for college. And at the time, it's interesting. You just never know where life is going to take you. I mean, I would have never predicted at that point in my life that I would be like sitting here hanging out with you guys talking about gut health. And so at that time, I actually thought that I was going to be able to take care of my health that I was going to be an adolescent psychiatrist. And again, like this was like the idealist in me where I was like, I want to help these kids. Like I feel bad for these kids. I feel like times are tough. I feel like times are even tougher now. Social meetings did not exist back then. So, but anyway, that's what I wanted to do. I actually worked at a camp in New Hampshire for kids with behavioral disorders. So it was basically inner city kids from Boston and Hartford, Connecticut. And I did that the summer after my junior year of college. And so I went into med school thinking I was going to be a pediatrician. And or like pediatrician with an adolescent focus or something of that variety. And you know, again, like you just never know, but I got into my third year and I love third year. It was amazing. But when I did my pizza rotation, I was like, I can't take these parents. They're either down your throat or they just don't care about their kid. And either way, I got a problem with that. So I was like, okay, fine, like I can deal with adults where you can just look, if they don't want to do what I recommend, that's on you, you're an adult. So I really enjoyed my medicine rotation. But the problem for me was I also wanted to use my hands in some way. And so I was looking for something that would sort of blend medicine and surgery at the same time. And when push came to shove, you know, I thought about like urology, ENT. And when push came to shove, I didn't love the OR as much as I loved working on a team doing medicine. So that's where I decided, okay, let me do medicine, but let me like have the most sort of surgical version of medicine that exists, which is GI. So, you know, I spent half my time doing procedures. And I mean, at that time, my gut health wasn't a thing at all. No one was talking about gut health. And so I went into GI, like truly, because my heart was in medicine, like internal medicine where I could take complex problems and peel them apart and think about them and figure them out. But then like I could, you know, the next day go in there and use my hands and fix something. So that's ultimately how I ended up in the fields that I did. I love that. I mean, and to your point about, you know, the field of pediatrics, my wife is a pediatric resident. And I hear these stories on a daily basis. Like when you shall come home and I could just see it on her face. You know, and now since we've been for the first time actually, we've been living together and I can tell what kind of parent she dealt with that day, whether it was the one who was completely just, you know, disconnected with their child situation or was it the parent that was giving her a hard time and making her life miserable. So yeah, and I couldn't agree more. I really enjoyed my pediatric rotation as well. It was so difficult to see, you know, when the patient, the child in front of you was paying for the parents mistakes, right? For instance, like secondhand smoking or maybe childhood obesity is also kind of on the rise now. Not kind of definitely on the rise. Just on the rise. Yeah. Yeah. And a lot of it had to do the choices that the parents made and we're going to talk more about that. Absolutely. Yeah. So, you know, you kind of touched on this topic of gut health and obviously that's what we're here to talk about. That's what we're here to learn about from you. So, you know, what is this? Most people have heard of the term microbiome. So maybe you could start about what that means. You could define that for us and maybe differentiate that between the microbiota. Like sometimes people use them interchangeably, but as I understand it, they're not one of the same. So. Yeah, I think it's probably good to start off with those terms and just kind of define what they are. So microbiota is referring to the actual microbes. That could include bacteria, fungi or yeast. It could include the archaea, archaea are my favorite, by the way. I knew nothing about archaea when I was in medical school and we don't all necessarily have them. But archaea are these single cellular organisms that are somewhere between fungi and bacteria. And we believe that they're actually the first creatures that we've done this planet four billion years ago, which is 1.5 billion years before oxygen existed. That's wild. It heads. They're extremely hardy. You'll find them like inside volcanoes and at the bottom of the ocean in a rift vent. And then you'll find them inside your colon. And actually, I was reading a study today looking at the archaea that we've inside our gut, inside of our gut, you know, one of our gut microbiota. And what they showed is that the archaea, they're interesting because they produce gas. But they also break down TMA, TMA is a chemical produced by our gut microbes when we consume carnitine or colon. That has been connected to coronary artery disease, chronic kidney disease, stroke. And so it's interesting because I guess, you know, we can dive in more to the microbiome, but like one of the big themes in the microbiome that I find very compelling is that we as humans, we always want to like identify the enemy and shoot it down. You know, what's the enemy? Let's destroy it. And one of the big themes that you learn in looking at the gut microbes is that like they, there's positives and negatives to so many of them. It's hard to define them as categorically good or bad. And we could show you as a villain though, Dr. B. Well, it's like Game of Thrones, right? Like what made Game of Thrones different and better, honestly, was that the characters had ducts, you know? So like what's his name, Jamie, from Game of Thrones, like that dude would have moments where he was like the greatest guy on the show and then you have moments where he's like someone give me a knife, I want to kill this guy, right? So and that's the way our gut microbes are, where it's like, you know, these are Kia. We could go and kill them and destroy them because they're causing gas and bloating. And that would be a mistake because they're protecting us from coronary artery disease, which is the number one killer in the United States. So anyway, to get back to the question that you gave me, the microbiota is describing the microbes. The microbiome, and some people use the word microbiome to sort of describe the microbes as well, but really a more appropriate use of the word microbiome is to describe the genetic, the genetic material that these microbes create. So it turns out, you know, that first of all, these gut microbes outnumber us. When I say that, I don't, I mean, like literally we have more microbial cells than we have human cells, no matter what way you look at it. So we are more than 50% human when you include any type of human cell or I'm sorry, we are more than 50% microbial when you include any type of cell. But if you were to like get rid of the red blood cells and the platelets and just look at the cells that actually have like a nucleus and, you know, Golgi complex and endoplasmic reticulum, all that stuff, what you would find is like these microbes outnumber those cells 10 to 1. So and that's where this idea of like we're only 10% human comes from, that we are like true human cells are being outnumbered 10 to 1 by these microbes. And that's nothing compared to the DNA, our DNA, like in terms of the human DNA that we carry 99.5% of our DNA comes from these microbes, 0.5% is human. And it's also part of what makes us unique. I mean, so don't get me wrong when I say this, like I'm not saying that it's our microbes that makes me look like I do and makes you look like you do, but our DNA, like Darsh, you and I, we have 99.99% the exact same human DNA, 99.99% but our gut microbes may literally be 100% different. And on a planet with 8 billion human souls, there are no two humans that have the exact same gut microbes profiles on the entire planet. It's like a, it's like a fingerprint, right? It's like a fingerprint and so, but the reason why the word microbiome becomes so important is it's not just the DNA, it's what that DNA activates, it's the function. It's what these microbes are capable of doing because that genetic code determines the functionality of these gut microbes. And this is where, you know, they're invisible, you can't see them, we can do CAT scans, where's the gut microbiota? Well, I don't know, but this is why we should define this as an organ because it serves a purpose in human health. It has a function, its function is to process our food, to create access to nutrients, to help us in terms of our digestion, to optimize our immune system, to regulate our metabolism, to balance our hormones, to affect our mood and the way that we think, even our impulses. And you know, even that human genetic code that we have, if you go back to when I was in med school, the early 2000s, that's when the human genome project took place and they cracked to the human genetic code for the first time, it was under Bill Clinton's presidency, they literally thought that they were going to cure cancer. Obviously, that hasn't happened. And the reason why is because we are not hard wired with predetermined health outcomes. Our genetic code is more like a switchboard. It's wired, there's switches, and you can flip those switches on or off. To activate. And the question is, who's sitting at the switchboard, flipping the switches? And the answer is these microbes. So we, you know, when you take a step back and you zoom out, you think about human health, digestion, access to nutrients, metabolism, immune system, the entire endocrine system, hormones, mood, brain health, genetic expression, my question is, what's left? That's everything that matters. I mean, that's that encompasses like the entirety of human health right there. And this is the reason why when people say it all starts in the gut, I actually think the right, it really does all start in the gut because you have to take care of this. And if you, if your gut is unhealthy, then you are putting yourself at risk for disease. And that's the reality. Yeah, I mean, that's both scary and exciting at the same time, you know, I mean, it's obviously, it's, like you said, it's definitely an organ by itself. But again, you know, in your world where this is what you've learned, this is what you train in fellowship, I think that you're probably having these conversations on a daily basis, or obviously in medical school, we, I mean, I, like you said, we're a little bit behind you, but we didn't learn about gut health at all. I mean, it was, you know, just at a superficial level, you're learning about these things. I want to go back to the archaea though, your favorite. You mentioned that not every individual has them. Do we, do we have a sense of what percent of the population has your archaea? It depends on where you go. It depends because gut microbiota profiles are very different based upon the, the, the, the culture, the community. So in the United States, when they've studied the United States, it appears that like, I believe it's about 35% of people have archaea. I see. But, um, but it really depends, you know, again, let me give you a quick example. So I'm on the scientific advisory board of this company that I love and I'm kind of really into their science called Zoe. And the thing about Zoe, what I dig is that I think this is the future of gut microbiome research because they're combining the gut microbiome with like really solid metabolic measures, like a continuous glucose monitor and a blood-whiped test. And so what's interesting is that Zoe did their initial research in the UK and then they started to apply it in the United States to American populations. And what we have discovered on the science board at Zoe is that the American microbiome is different than the UK microbiome, which is really surprising. So a quick example, there is this, um, it's actually technically a parasite called blast assistus. Uh-huh. Now, most people would think, oh, blast assistus parasite, like that must be bad. It's a parasite. You know, the blast assistus is our friend and it's good for us from a metabolic perspective. And in the UK, about one in three people have a blast that have the blast assistus. In the US, it's actually a lot less. It's a fraction of that. And so it's just kind of interesting, like, why would that be? What's the big difference? Like, they seem like they're, is it the fluoride and the water, like, what's the difference? So I, I'd, to answer your question, a normal gut microbiome depends on where you are looking. And, um, our gut microbiome is adapted to the life that we weed here in the United States and the conditions that we put it through. That's really interesting. I mean, you, I mean, that, that idea of it being almost a preventative measure for a coronary artery disease, like, as you mentioned, the number one killer in the world. Yeah. Now, I, I wonder if at some point, and maybe you have some insight to this, because you are on, uh, as an advisor to this company who was doing a lot of cool things. I wonder if, you know, just like we look at a lot of different biomarkers, like APOB and you look at somebody's lipid panel, you look at their A1C to determine risk for, you know, CAD and diabetes and all those things, if it would be premature to say that we could look at this as a preventative measure or say that you are, like, so I guess what I'm asking is, if you don't have this, do you think are, are you at a greater risk, or is it just that it's truly just, hey, it's preventative that, you know, even if you have other risk factors, maybe you might be better off to have this, which one do you think it is? Well, I think at the end of the day, the looking at the gut microbiome, it is not meant for us to pick out one bug, you know, whether it's the archaea or the blastocystis or one of the other ones, it's not, things don't function in a vacuum, picking out one bug and being like, oh, this does this, it doesn't work that way, context is critically important, right? You could take the exact same bug, but if you surround it just like us, like as humans, right? Like, when you behave different, you're the same person, but you behave differently depending on whether you're hanging out with your wife or your buddies or you're in your residency, like in that, like, you know, cave where you hang out with your co-residents and you're just having fun and cutting off some steam, right? And so you're the same person, but context can affect the part of your personality that comes out. And that's the way it works with these gut bugs. So I think at the end of the day, it's not so simple as like, do you have archaea and therefore we're defining your risk of coronary artery disease? And I know that's not what you were implying. Yeah. But just to kind of unpack, you know, the way that we're going to go about this, ultimately at the end of the day, what we need is we need large data sets with tons of people. We need to measure outcomes because at the end of the day, that's what we're looking at. Like, do you get this? We're not going to get this. And along that path, granularity of detail is going to allow us to disentangle the complexities that exist. And so we're entering into, you know, I don't know how much you guys sit around and think about this, but I'm like a big time nerd. And so I think about this kind of stuff. We're entering into an interesting time in clinical research because in the past, clinical research, you basically had to accept the weaknesses of the methodology that you were applying. So you could do a large scale population study and the beauty of that was statistical power and looking at big numbers, but the problem is you lose the granularity. You lose the detail. So you make that sacrifice in the process. So how many times have we heard people say, well, the survey that you use is not good enough, even though you have 100,000 people in your study. And the flip side of that is the small scale stuff, like in a lab, where you have tons of granularity, tons of control that you can measure. But it's not the same as having a big population-based study, right? So now here we are for the first time. It's really cool because these things are coming together. We're coming together. Zoey as an example, it's not the only one that exists out there of this variety, but Zoey as an example is large scale population data, but at the same time, having high levels of detail of a person's microbiome, their continuous glucose monitor, what they're eating by using an app. And so it's just really exciting to imagine that this is like, we're going to start tapping into an answer in questions that in the past, we haven't been able to tap into an answer because we never have the ability to access data the way that we currently do. And part of it is honestly, we don't think about this, but it's the computers. We needed the computer power. So that's a big part of where things are going, and I think it's really exciting. Yeah, that's absolutely wild. And me and Ultima to talk about all the time is, how do we make medicine more individualized, right? And that kind of touches on it. And I know we're going to talk about it a little bit more further down this conversation. Dr. Bee, I want to start off this gut health as well in terms of talking about what can go wrong, right? We look at chronic conditions globally, right? We're seeing a rise of type 2 diabetes, cardiovascular disease, COPD, et cetera, et cetera, et cetera. The list goes on. And a lot of it can be linked to gut health, like we said, right? Let's treat the gut. What are those things that can go wrong with the microbiome? One of the terms I keep hearing, getting thrown around is leaky gut. Can you kind of explain what that is? Yeah, leaky gut is a term that predated in many ways our ability to fully unpack and understand the science. So the term was already floating around out there, and I do give credit to the alternative health space that was sort of identifying this connection. I mean, they sort of already identified that, well, gosh, when your gut is messed up, these issues, these problems start to arise. But we really had to get into the details of how this works. And leaky gut, to me, like, can you use that expression and still call yourself a scientist? Sure. You can. It's increased intestinal permeability. But we have to make sure that we are properly defining what we're talking about. So leaky gut, to me, is a part of a package that I would describe as dysbiosis. Dysbiosis is really more of an appropriate scientific or medical term. And really what it means is there's sort of three parts to this, to dysbiosis. So let me describe this. Number one, it's the gut bugs. There's a loss of balance, a loss of harmony. Think of the gut as an ecosystem, because you should, it is an ecosystem. And just like in any ecosystem, when things get out of whack, all of a sudden you see things start to fall apart, they're not working the way they're supposed to. Less good guys, more bad guys, loss of biodiversity. These are the measures or the characteristics of a ecosystem under duress. And that's what you see in your gut. And that initiates dysbiosis. And when this happens, the lining of the gut, the epithelial layer that lines the intestines is held together by essentially like spot welds that are the tight junctions. And those tight junctions are maintained in part by a healthy gut microbiota that is producing short-chain fatty acids that we get from fiber. So when the gut bugs are out of whack and dysbiosis sets in, and they're not producing the chemicals that our body needs to uphold itself, these tight junctions break down. And you basically are opening things up and you're increasing the intestinal permeability, which is leaky gut. Yeah. And then what happens, sorry, the third part real quick is that you actually do have leakage of intestinal contents that are not supposed to get into the bloodstream. And the classic example of this is bacterial endotoxin, which of course we refer to as lipopolysaccharide. Right. And that's produced by the gram-negative bugs that exist within our gut. That lipopolysaccharide, it already is there inside the movement of our intestine, but it can't get into our bloodstream when the tight junctions are intact. So when you have this sequence of events damaged to the gut bugs, break down to the tight junctions, increasing intestinal permeability and leakage of lipopolysaccharide, this is essentially a setup for chronic inflammation or inflammation of some variety. Right. That's absolutely crazy to think about, right? I think when most people think about the gut, they think about this strong walled, you know, not a super thin paper slice kind of barrier that we have from like our blood and the rest of the things that are, that these foreign invaders can come out of. So how do we destroy the microbiome? What are some ways that we do that? Is it by the food that we eat or is there other lifestyle choices mainly? Well, it's a rather complex issue in some ways because part of it is that we inherit our gut from our family. So the beauty of it, by the way, is taking an optimistic outlook is that it is extremely moldable and adaptable. We have clinical research studies where people change their diet and in less than 24 hours, you can already see changes occurring in the gut bugs. And the reason why it happens so quickly is that it's, they're on a different time scale than we are. So us humans, it takes us like, you know, like in theory, 20 years or 30 years to procreate a new generation. These gut bugs are procrating a new generation in 20 minutes. In an hour, they have three new generations that they've kicked out. Also if you think about that from an evolutionary perspective, the food that you put in your mouth is triggering a cascade of evolution among these gut bugs. That's occurring very quickly over the course of just 24 hours. And so anyway, in less than 24 hours with your diet, you can change your gut bugs. And diet is the, let's just be upfront and say like diet is the number one driver. The food choices that you make, the three pounds of food per day, the thousand pounds of food per year, 80,000 pounds of food during your lifetime. That's what's going to determine the makeup of your gut bugs. But at the same time, it's kind of interesting because our gut microbiome is where we kind of interact with the outside world. It's an expression of the entirety of our environment. So let me give you some examples. Your sleep affects your gut bugs, movement, exercise affects your gut bugs. The people that you spend time with, the people that you share a home with, they've shown that the other people that live in the house with you, you start to have a gut microbiome more similar to one another. Wow. Which makes me feel really good because my wife then therefore is generously making me better than I am. So having a pet, having a pet, spending time outdoors. So you know, each of these things, like if you think about the consummation of diet and lifestyle, the way you eat, the way you of your life, all of these things come together and ultimately create this balance and the problem is that, you know, yes to me, Darsh, like what's changed? Why is our gut under attack? Yeah. Think about how radically different our life is today compared to 100 years ago. Yeah. Totally. And someone didn't exist, like, and someone didn't exist 100 years ago. You know, we didn't have all these things that we clean our bodies with, clean our homes with. We didn't have the stuff that we're spraying on our food. There were very few processed foods 100 years ago. There were a couple, but like, that wasn't a big part of the diet. I mean, most people, they had to cook their food and they knew their farmer and their farmer wasn't putting anything on the field. And so, you know, exercise, like, there was no TV 100 years ago, but alone, an iPhone or an iPad or a laptop, silly stuff, like some like, silly stuff, like blue light, you know, we're all sitting here, we're talking to one another and we're basically like shooting light towards the back of our eye in our retina. And that's throwing off our melatonin and you throw off your melatonin and you throw off your circadian rhythm and you throw up your circadian rhythm and that affects your gut microbiome. It's all connected. Yeah. It's all connected. And so what's the way, he's two steps ahead of you. If you see those glasses right there, there are blocking that blue light. So only 50% that's awesome, but I did want to say, so I thought about this beautiful poetry in a way, right? So as you talk about how the environment affects our gut microbiome from the actions we take from the people we live, things that are in our control and out of our control and how our gut microbiome can be this intermediate step because we now know that there's this gut-brain connection, right? In fact, in things like depression, mood, and so the gut microbiome also in a way is in charge of our expression towards other people in the world that we interact with, right? And it's kind of just this full cycle. So I just thought that was kind of cool. But I did want to talk about food because you did mention how that's probably the most influential thing on our gut microbiome in today's world. As you know, there's so many different bad diets or just different diets out there in general. And even within those diets, people are saying, hey, gluten-free on this packaging or I should go dairy-free. What's the word on gluten and dairy? It's a wonderful question, I know. That is a fully loaded question. All right, so I guess let me take on dairy first because it's quick, you know, I can kind of like, I can kind of like get that done with and discard it and then turn my attention to the gluten because that's going to be more of a struggle. So dairy, the issue with dairy is, so let me start by saying this. I think it's important for people to understand. I literally say this to my patients all the time. Nutrition is about substitutions. There are always choices that you can make that are healthier. There are always choices that you can make that are less healthy unless you're talking about trans fats. That's the bottom of the barrel. Like, that's as far down as we can go. But there's always going to be better, there's always going to be worse. To call a food good or bad is a little bit silly because at the end of the day, it's all gray, shade's a gray, and you can line them up and create sort of this list or pyramid of what's at the top and what's at the bottom. And when you come to dairy and you talk about the dairy and gut health, there's clearly worse than dairy. So I don't want to sit here and pretend that this is the number one driver of GI issues or gut health issues that exists. The biggest issue with dairy truly is the lactose. And lactose is a carbohydrate found in dairy that 70% of the world is lactose intolerant. And what that means is that when they consume dairy, if they consume more than their gut is capable of processing, then they will have symptoms, like gas, bloating, diarrhea, things like that. All right. But that's a threshold event, that's not an allergy, right? Like an allergy, if I have a dairy allergy and you put two drops of milk on my tongue, I will react to that. If I have lactose intolerance, I could have the worse lactose intolerance on the planet. You put two drops of milk on my tongue, I'm not going to have a problem. There's some point at which you start adding this and it will cause trouble. And the interesting thing about it is that lactose, which we vilify, is actually a conditional prebiotic. It actually feeds the gut microbiome. Conditional, the reason why I use that word to describe it is that it's not always a prebiotic. It has to be certain conditions met in order for it to actually get down to the colon and feed the gut bugs. But you can train your body to be better at processing dairy. So when people consume dairy and they get gas bloating, diarrhea, their lactose intolerance, they're not capable at that moment of consuming that amount of dairy. But if they were to actually work on it and train their gut like a muscle, you can actually enhance your ability to process the lactose and get to the point that you can consume a lot more than you think your capable of. Now I'm not here to advocate for the consumption of dairy. Let me just say like I personally don't consume dairy. My choice, a big part of that is what I view as the health risks. And there was a great review article published in the New and the Journal of Medicine by Walter Willett. So for people who are listening to this, if you're interested or you're trying to figure out what to do with dairy, read this review article by Walter Willett who's from the Harvard School of Public Health. And he basically weighs out the way that he sees it. And there's some advantages, dairy is good for colon cancer, it protects us. But on the flip side, dramatically increased risk of prostate cancer. And we always think of dairy as protecting us from fractures, like helping our bones. You guys are in physical medicine or rehab. When they line this up and they look at populations, the people who consume the most dairy have the most fractures. Yeah, I think you can take that into Europe, right? The studies in Europe have shown that like in the northern Europe, right? Exactly. So I think it's a personal choice on whether or not you want to consume dairy. Do I think that dairy is the root cause of the health problems that exist? No, I think what it is, is that when you have a damaged gut, when you have a damaged gut, you are less capable of processing lactose and you're going to feel it. And so this is basically exposing the fact that you have a damaged gut, it's not causing the damage. I mean, could it contribute to the damage, yes, it can. It's quite debatable whether or not dairy is bad or good for our gut health, to be honest with you. For me, my concern with dairy is more like, I don't want prostate cancer, that's what my grandfather died from. I see. So all right, but gluten is interesting because gluten took off as like a really big fat thing where it was a couple of books that came out and there are some studies looking at gluten and intestinal permeability, but here's the problem with these studies. I want people to understand, to do something in a test tube is not the same as to feed me a slice of bread. It's just not. And when they've done gluten studies to say that gluten causes harm to the gut, it's always test tube studies. It's just not that you can't expect that to always translate. There's a reason why test tube studies are always verified in real humans. And when they've studied in real humans, they give them wheat. What they find is actually their gut microbiome gets healthier. Why? Because wheat is not just gluten. It contains a whole bunch of stuff, including a lot of wonderfully healthy pre-biotics that feed our gut microbiota. And so like we don't consume gluten in isolation, we consume wheat, we consume bread. Can gluten-containing products be unhealthy 100 percent? It's called processed foods, like ultra processed foods. Those are unhealthy foods. And it's not the gluten by itself that makes it healthier unhealthy, so just unhealthy foods. So there are people who have a wheat allergy. There are people who have celiac disease. Those two combined make up about two to three percent of Americans. It's not a very high number. And the rest of the people who think that they have a gluten problem, they probably don't have as much of a gluten problem as they actually do. You guys have a quick moment, can I tell you one of my favorite studies? I have to choose. Yeah. Okay. Cool. So you know everyone says gluten, I got gluten sensitivity. We've mislabeled it to call it gluten sensitivity, it's not a gluten sensitivity. If you take a population of people that do not have celiac disease, they actually did this study. Take a population of people that you have verified that they do not have celiac disease. And what they did in this study is they gave them three weeks worth of breakfast bars. Each week was a different bar. So you would get a placebo for a week. You would get a breakfast bar that like literally contained gluten in concentration. And then the third thing was a bar that contained fruit tans. These are FOD maps, it's the fermentable part of our food. Just like lactose is a FOD map, fruit tans are FOD maps that you will find in wheat. And so they gave these people the three weeks worth of bars, they concealed it and they had them record their symptoms. Of course, the placebo is the control, right, so we compared it to that. Here's what they found. Compared to the placebo, when they consumed the gluten containing bars, they had less symptoms. Less symptoms consuming gluten than the fricking placebo. But when they consumed the fruit tan containing bar, they got triggered. Because the entire idea of calling it a gluten sensitivity, it's not a gluten sensitivity. It's a fruit tan sensitivity. And that's because wheat doesn't just contain gluten, it contains fruit tans. And by the way, fruit tans are actually really good for us, they're pre-botic. But if you have a damaged gut, just like with lactose, it can make you feel it. And you have to reduce the amount that you're consuming and train your gut. Yeah, I mean, that's not surprising to me, I mean, Dr. B, this goes back to that concept of what we started the conversation with, right, we always need a bad guy, right? And so what, 50 years ago, it was just fat, right, when Ansel Kees time came around, and it was carbs or the bad guy, then it was gluten. I forget what it was over the last couple of years, it's, it's, feel like it's turning over faster and faster. Like the instant, yes, exactly, right, right, right. I love that what you mentioned earlier, though, you said that, you know, food is all about substitutions. And this kind of reminds me one of our previous guests, you know, EC Sinkowski, she kind of spreads the same message that you do about getting more veggies in, you know, and she's got this 800 gram challenge and the premise of it is try to get 800 grams a day in fruits and veggies, and you'd be amazed by how much volume that is, and you don't have a lot of room left over for the crap, right, for the processed foods. And so earlier, you said that you really don't consume any dairy at all. Is that correct? That's correct. So I'm curious. What is your diet like? I mean, could you take us in, you know, a day in the life of Dr. B, like, what do you eat? What do you eat? What's your diet like? Yeah, no, I get that. And, you know, it's, it's kind of funny because so I described my diet as plant-based. Okay. Okay. I separate that from vegan, and to me, that's an important distinction because I don't, I don't know that most people see it exactly this way or fully think, like, think about these ideas. But to me, veganism means that you are motivated by animal welfare and the environment. And so is the absence of animal products. But like, that's it. That's the way we rule. That's the absence of animal products. And you could eat Oreos all day and Oreos are vegan. And that's a vegan diet. And that's, that's one of the things we have to be careful about in clinical research studies is that people will look at vegan diets and be like, oh, that's, that's a, that's not that healthy of a diet. And it's like, yeah, that's because it's a vegan diet where they're avoiding animal products. They're not necessarily eating more plants. So anyway, I call it plant-based because when I think you're motivated by human health, that's what I'm motivated by and like you guys were doctors, right? So when I think about patients, I'm thinking about, how do I get them healthier? And I think the plants are the way. So for me, this was a radical change. If you went back eight years ago, I was like a junk food junkie, tons of, tons of fast food, tons of processed food. Now where I am, let me, let me get you some examples of some of my favorites. Breakfast. I love breakfast. Breakfast is phenomenal. You get great options because you can do smoothies. You can do smoothie bowls. If you follow me on Instagram, you've seen my smoothie bowls. I put tons of different toppings out there. I have fun with it. If you want savory, you go with avocado toast. I'll hit my avocado toast with a bunch of balsamic vinegar, garlic, and cayenne pepper. I love it. All right, put that on some sourdough. If you want sweet, you could go, I mean, again, you could do the smoothie. You could also go with peanut butter toast, put some berries on top, hit it with some cinnamon. You could go with oatmeal. You could do your oatmeal to the traditional way, nuts, berries on top, or you go with oatmeal and do overnight oats. So quite simply oatmeal with some plant milk, throw some blueberries, and maybe some walnuts in there, maybe some chia seeds, and you're good to go. Shea pudding. If you've never tried chia pudding, it's incredible. And it's so good for you. And so, you know, like, I'm talking about food that's delicious, and it's almost unfair how healthy it is considering how good it tastes. Lunch. I eat the same general types of lunch that anyone else does. Soups, salads, and sandwiches. The difference is the mine are plant-based. So like, I'm not having a cold-cut sub sandwich, right? But soups, salad, and sandwiches, the type of stuff, most of the time for me, salad is leading the charge in that department. And then dinner for us as a family, like the backbone of our diet is whole grains and legumes. So you start with this concept of, like, take a whole grain and a legume that you like, and then pick out what ethnic food or, like, flavor profile from around the world that you dig and build from there. So like, we could go and do a Mexican bowl. We could do more of a Southeast Asian flavor profile. We could go and do a curry bowl, right? And that's the kind of stuff that we do, or we'll do, sometimes we'll do, like, a whole wheat pasta with tomato sauce and put, like, a whole bunch of veggies in there, all right? So everything that I just mentioned calls for cilantro, except for one, the tomato sauce calls for basil. But, I mean, basically, this is the kind of stuff. So, you know, I think the intimidating part for people is, what am I going to eat? And am I going to miss my old food? And what's interesting is your taste buds change, and you start to crave these new foods that are nourishing your body, where actually you feel better, you feel lighter, you feel more energetic, and you start to feel like, I don't want to go back to what I was feeling before. So, but I think where it starts in terms of building healthy habits is just setting realistic expectations, and taking one step, just one step, like, find one recipe that you dig. If you get my book, Fiber Fueled, I have 80 recipes in the back, like, pick up literally one and try it. If you go, I'm friends with the minimalist baker, Dana, she has, like, hundreds of recipes and they all take 15 minutes, and they're amazing. So, I mean, that's the way to go about starting. Absolutely. I mean, you know, you got to make it simple, like you mentioned, right? I mean, everything that you've mentioned, it doesn't seem like, I mean, once you get the ideas, the preparation process doesn't seem like it's intensive. I mean, and that's one of the complaints or the feedback I'll get from a lot of individuals when we're talking about eating and preparing vegetables, they'll say, oh, I don't have the time to do that, right? Today's world, everything is go-go-go, I mean, where residents, where else is it go-go-go? So, you know, it's funny, actually, I was back home and my parents this past weekend and I was just kind of yelling at them, there were no vegetables, like, you know, in a very respectful, loving way. And my mom said, oh, you know, dad goes grocery shopping, like, once every two weeks and he just gets too much food. And I was like, well, we got to go more frequently because you obviously can't have fresh vegetables in the fridge. But, and then, you know, so this is all the more reason to pick up your book, so you have all these ideas. I do, one thing I didn't hear you mention, again, going this idea that Dorshan and I are residents, he doesn't drink a lot of coffee, but I might as well have an IV attached. What are your thoughts about caffeine? I mean, because obviously the coffee, I mean, it's good, it's bad, but it can be pretty acidic, right? I mean, so I haven't come across this and I haven't thought about it this until now. I mean, can that be damaging or toxic to the gut in terms of the microbiota? Like, in terms of the coffee content, are there better types of caffeine for it? Anything we know about that? Yeah, actually, there's quite a bit that we know. So let me, let me be completely upfront and deliver my disclosure statement, which is that I love coffee. So any time that there's a research study that says the coffee is good for us, I automatically celebrate and that's what I'm going to talk about when I go on podcasts. Perfect. So, but, you know, to break this down, I mean, somewhere to the gluten issue, you know, so easy to look at coffee and be like, oh, that's caffeine. But it's not. Like, it's coffee and a coffee contains caffeine and it contains all this other stuff too. And what's interesting is that coffee contains polyphenols. Polyphenols are antioxidant compounds, they're essentially anti-inflammatory. They come from plants, which of course, coffee comes from a plant. And these polyphenols that you'll find in coffee actually are pre-botic and beneficial to the gut microbiota. So we believe in general that coffee, like generally speaking, not on an individual basis because obviously we're all unique, but generally speaking, we actually think coffee, black coffee, is good for us. And perhaps what's even better is tea, particularly green tea, like matcha. Matcha has extremely high levels of polyphenols. And those polyphenols are so good for gut microbiome and they're anti-inflammatory and wonderful. All right. So, I think coffee and tea are completely in play. That being said, the caveat ultimately is that if you have acid reflux, you may find that it makes it worse. If you have urinal bowel syndrome, it may give you diarrhea, or it may make your urinal bowel syndrome worse, so you may need to back off of it. And some people have a genetic condition where actually they get diarrhea from coffee. So just be aware of that. Man, Dr. B, you're listing off all these foods. And just let you guys know, I'm slowly getting on the coffee bandwagon, all right, all to so, you know, I'm slowly getting a one cup a day here and there. But that should be you're listing off these foods. I'm plant-based myself, you know, and I love the smoothies in the morning. And, you know, if I were a patient of yours, man, I don't know if I'd be able to sit around for five minutes, you list off these foods, I'd be getting out the door and going to go make something. But I do want to talk about your practice. When you look back and when you chose to go GI, are you surprised by how you currently practice now from what you envisioned back when you first chose to do GI? 100%, but I think at the end of the day, at the end of the day, the choices that you make along this path. This is a journey that we're all on, right? And we're each at our own, like, position in terms of where we are in the journey. You know, you guys are right now wrapping up, like, darsher in your intern year, ultimatum, you're wrapping up your residency, you're getting ready to move on to your fellowship. And, you know, we each are kind of like going down this path. And what you need to do, I think, this is my advice to people who are early in this process, is remember why you chose to do this in the first place. And don't ever let go of that, because the system can make you so cynical, and people are going to beat you up. I get beat up all the time. Like people don't care what my reputation is, they want to smash me sometimes. And so, but you got to remember why you're doing this, because there's something beautiful there that's motivated by humanity, and caring, and compassion, and love, and that's really what's important here. If it was about the money, you should have been a banker, and I don't know what you're doing, you should probably quit right now and go do that. Terrible fun. I'm an investment. So, I think that that's an important part of it, and I think the other thing is be a lifelong learner, and be prepared to adapt. So, you know, I finished my fellowship, and I went into practice. And that's when I started exploring these ideas, was after I finished my education, you really just started there. Okay. Yeah. So, taking everything we just kind of talked about, how do you incorporate this into your patients' lifestyles? What are the things you tell them, what are the things you focus on? Well, I think, you know, so the important thing, it can sound very overwhelming to other healthcare providers when I talk about it like this, and they think that I'm like spending an hour with every patient doing the nutritional counsel, and that's not true. I think that the way that I see it is I am there to provide the high level guidance to my individual patient. I don't treat exclusively with diet and nutrition. I don't avoid medications when they're appropriate and needed, and in many of my patients, diet and nutrition doesn't become a part of the plan until the second or third visit. So, for me, my process is the same process as every other doctor. What am I treating? Let me figure that out first. Once I know what I'm treating, then I'm going to get laser-focused in terms of building out a plan, and I think the difference for me relative to where I was during my training is that now my plan always includes a conversation about diet and lifestyle. When I tailor it to the individual, you have to be able to look and read the body language of that individual. You have to be able to tell where they are. This is part of the reason why in my book, I always set progress over perfection, because I have tons of patients who are eating a trashy diet, and I'm not going to sit there and tell them you need to be 100% plant-based, they would never do that. So, if I can take their trashy diet, which by the way is very similar to the way that I used to eat, and I can move the needle and get them from 10% plant-based to the 25% plant-based, I've done something really good for that person. So I try to set realistic expectations. I try to celebrate progress of any variety, no matter how small it is. And the other thing is I think of this as a team-based approach. So for every person who's in healthcare out there regardless of whether you're a doctor or you're not a doctor, if you're in healthcare, I would encourage you to think about how you build your team. And for me, I have a registered dietitian in town. She's not employed by me, but I have a great relationship with her. She does an amazing job with my patients, and so I basically include her very early in the process. So I will set the direction, I will point the compass, and then I'll hand off to my teammate, and my teammate will basically reinforce everything that I started. That's the way I approach that. I love that doctor. I mean, it has to be a team-based approach, otherwise it's not going to be successful. I mean, it would be so foolish for anybody to think that they can do it all. I mean, we just don't have the time, the resources, and also getting another person's perspective is so helpful, because sometimes there's things that you can miss, and just having your team-bed have your back is super helpful. How much time do you spend doing procedures? What percentage of your practice are you? I'm about 50% of my time in town. And do you do any inpatient time, or are you doing any rounding or consults at this time or no? So I take call, we are a small practice, this is crazy, and it's going to sound insane when I describe this. I'm on call Q3, but it's a very white call, and so I cover two hospitals, the hospitals are small, and I see patients like, for example, I had a consult yesterday, I was on call yesterday, I had a consult for GI bleeder, and so I saw the consult yesterday, I did the procedure today, so I spend a little bit of time in the hospital, but it's not in the way that you guys are in the hospital as residents, where it's not like full time in the hospital for the time. Gotcha. Okay. I mean, that definitely helps, and we initially say Q3 call, I just think about what we were talking offline about the ICU people, but this sounds definitely a little bit better. Well, you know what, let me, it's a great point because I know that we have a lot of listeners who are going through the process of coming up in medicine, and I should share this real quick, because I think it's important for people to understand. When I came out, you have to decide what you want, and you have to also understand that money does not grow on trees, and practices don't have some magic formula to make more money. They don't. If doctors are making more money, it's because they're working harder. Yeah. And you have to decide where your threshold is, because when you come out, it's very easy to be attracted by big numbers, and get sucked into a scenario that you don't like. So I came out of my fellowship, and I took a job in a practice, which was of high earning G.I. practice, and the call was Q8, okay, so that sounds super attractive. Like, dang, you're going to make money, and you're going to call Q8, okay, so, but let's break this down. My Q8 call, when I was on call, I could not sleep in the bed with my wife, because it was not a question, it was not a question whether or not I was going to be up in the middle of the night, and it was not a question whether or not I was going to the hospital. The question was, what time are you going to the hospital, and how many times will you be going into the hospital in the middle of the night? All right, so you get to the point, even though it's Q8, where if you hate being on call so much, that's unhealthy. And my Q3 call, I take call all the time, but my call is light, so I don't fear it at all, okay, and then the other thing that I want to point out is, I think it's really important, and I think you guys appreciate this being in physical medicine and rehab, but not all doctors appreciate this, you deserve to have a life, you deserve to be more than just a doctor, medicine will consume you if you will allow it to. If you don't draw the line in the sand, you're going to get chewed up by it, and this is the reason why burnout is like absurdly high among young attendings, like I had friends that are again burned out, you know, and we're only a couple of years out of our training. And so you have to be prepared to make a decision of how much time do you need for yourself, and you should protect that. And so when I came out of fellowship and I saw this big opportunity to make a ton of money, well, guess what that was? That was working 90 hours a week, six days a week, you know, I had a daughter who was a newborn at that time, and I'd go like literally all week and not see her, and you start to hate yourself when that's the case. And now the practice that I'm in, I took a more than six figure pay cup to be in this practice, but I work four days a week. And it gives me flexibility with my time, it gives me more time with my family, and frankly, it is what has allowed me to do all the things that you see me doing like Instagram and write books because I created time for myself. And those things, even though they may have the appearance on the outside of being a business, they were never meant to be a business. This is just a passion project. I did it for fun. Here's a quick message from our sponsor, Comp Health. There are a lot of podcasts out there, murder mysteries, breaking news, there's even a podcast about garden notes. And instead, you're here learning how to be the best version of yourself, smart move. Do you know what else is a smart move? Working a Locum tenant assignment with Comp Health. Now I know what you're thinking, if you are a physician, you already have a job. That's the best part. You can work flexible, local assignments on the side for extra income, or you can work Locum's full time too. And to top it all off, Locum's almost always pays more on average, just head to financialresidency.com for slash Comp Health and see what Locum's can do for you financially. And now back to the show. Absolutely, I mean, it's allowed you to work on your passion and that's why you, I think you recently had fiber fuel just had its first birthday, not too long ago, am I correct? Yeah, I mean, over 100 and what, 50,000 copies, I think you're doing okay. But you know, something you mentioned earlier about, you're very particular about making the right diagnosis, because that's going to gear your management, right? And it kind of reminds me of one of my mentor always says, there's only two X's that matter, DX and RX. And you can't have one without the other, right? I mean, because that's why we have to have a very good diagnosis because otherwise you might just go down the wrong pathway and you're chasing something else. And then you have all this unnecessary treatment, unnecessary costs, unnecessary harm to the patient. It's all about, especially if you're doing it for the right reasons. And so I want to maybe in a second, we'll talk about how can we train the gut, but maybe obviously, maybe we could talk about how, why we have this epidemic of just poor gut health and dysbiosis. I mean, I imagine it has multiple causes, but one of them, as you've mentioned so many other times, is the lack of fiber in our diet. So maybe you could give us some of the statistics on what the average American diet is like and how the lack of fiber contributes and what kind of inspired you to kind of write fiber field. Yeah. The average American's diet, if you look at it, again, like this may not be you, the person who's sitting here listening to us right now, but if you look across the United States, the average American's diet is about 60% processed foods, ultra processed foods. That's 60% of their calories, and about 30% of their calories come from animal products. So meat, dairy, and eggs. The average American eats their body weight plus an extra 40 pounds, which by the way is the size of a five-year-old child in meat on a yearly basis. And yet some people would tell us we should do more. It's more than any country in the world. Us, Australia, and the UK are top three. So the English colonies were leading the charge in terms of meat consumption. China's coming up. They're eating a lot more now. So but that's the American diet, 60% processed food, 30% animal products. And what I just described there, 90% of your diet contains virtually zero fiber. Animal products, that 30% is zero fiber. Most foods, very, very little fiber. And what's left, the 10% fruits, vegetables, whole grain seeds, nuts, and legumes. That's the last 10%, but here's the problem. What's the number one part of that 10%? Potatoes, french fries, and potato chips. Like, come on, man, that ain't right. So we need to change this. And if you ask me where the issue lies, the issue lies in this. I said that diet is the number one predictor of your gut microbiome. You have control. You can change your diet and change your microbiome in 24 hours. These are your choices. Fiber is the preferred food of your gut bugs. This is what they eat. This is what energizes them. If they are not fed fiber, they grow weak. And eventually at some point, they become incapable of doing their job. So the average American is getting 15 to 18 grams of fiber per day. The recommended amount is for women, 25 grams, for men, 38, as a minimum, 25 for women, 38 for men, as a minimum. You guys look at fiber studies. Next time the fiber study comes up in the United States, take a look at it. The typical methodology that they will use is they will break fiber consumption into quintiles, right? 20% 20% 20% down the line. And they'll compare the high fiber consumers to the low fiber consumers. The low fiber consumers in the United States are getting 8 grams of fiber per day. What? Wow. That is ridiculous. You have to try to be that well. That's absurd. And the high fiber consumers are even more depressing to me. Because we're talking about the top consumers of fiber. And they average like 22 grams of fiber. So even the high fiber consumers in the United States are getting less than the recommended amount of fiber that we're supposed to have. And so the problem that exists, for people who are curious, I know we're running short a little bit on time here. For people who are curious, I would really encourage you to read the paper, David at all, Warren's David, Nature 2014. Because in this paper, they compared, it was a 2014 paper published in Nature. They compare five days on a completely plant-based diet to five days on an animal-based diet. And what you see is during these five days on a plant-based diet, you are growing your microbiome, it is becoming stronger, it is producing more short-chain fatty acids in just five days. But when you flip that over to an animal-product-based diet, only meat, dairy, and eggs, fiber content is zero. Short-chain fatty acids fall off the cliff. And instead, who rolls into town, bacteria like biofill, what's worth you, that's been connected to inflammatory bowel disease, all the types of putridinous, which has been connected to appendicitis and to colorectal cancer, bacteriodes that's been connected to colorectal cancer. In just five days, you can see these changes. And so, the problem in the United States is that we are tipping the scale in the wrong direction. We're removing the fiber, and we're replacing it with junk. And it's pulling it all down in the wrong way. And so this is why I felt compelled to write my book. And I went to sell this book onto the title Fiber Fueled, and people told me, a book about fiber will never sell. And but at the end of the day, I felt like this was the message that people needed to hear. And so... No, absolutely. I mean, I've read it, and I've learned tremendously from it, you know, being someone in healthcare itself. You mentioned Dr. B. Short-chain fatty acids. What are they and why are they so important? Short-chain fatty acids are the part of nutrition that we're not talking about, and everything one of us should be. Short-chain fatty acids are produced from dietary fiber, butyrate acetate and propryonate. Those are the three main short-chain fatty acids. And they are powerful anti-inflammatory molecules. When you talk about dysbiosis, Darshan, we were talking about dysbiosis earlier. You need to rebalance the gut microbes. Short-chain fatty acids do that. You need to repair the tight junctions. Short-chain fatty acids do that. You need to reduce the lipopolysac ride rows. They do that too. They directly protect us from colorectal cancer. They optimize our immune system. They activate satiety hormones, which is a very important thing when you consider the amount of obesity that exists. They activate satiety hormones, so you stop eating. They actually help with insulin sensitivity. They lower cholesterol. They lower blood pressure. We have evidence to suggest that they may protect us from coronary artery disease. We have evidence to suggest that they may protect us from Alzheimer's disease. I mean, basically, if you go down the line, I can make a compelling argument that six of the 10 leading causes of death can be prevented by increasing short-chain fatty acids, but the problem is, if you want them, you need to consume fiber. Well, so fiber seems like the solution. And I think most people when they think of fiber, they think of something that comes a little orange can, maybe, metamusel. Tell us why that's not what people should think of when they think of fiber. How many different types of fiber are there? We don't even know how many types of fiber there are. Fiber is incredibly biochemically complex. I was a chemistry major in college. I have no clue how to describe fiber. It's crazy. And so, but what we do know is this. There are an innumerable number of types of fiber, and each plant has fiber. Each plant has multiple different types of fiber. And those unique types of fiber are food for the gut microbes, and they don't all eat the same thing. These gut microbes, they don't just want kale. If you eat kale, there's certain gut microbes that will eat it, and they'll thrive, and they'll do well, but there's other ones that are still waiting for their meal. If you eat beans, then maybe these other microbes they get to eat now. Each plant will feed specific families of microbes. We mentioned before biodiversity. We want biodiversity within our gut microbiota. That's a measure of health and resilience and strength within the ecosystem. How do we get biodiversity within our gut microbes? Through biodiversity within our diet. Eating a wide variety of plants, as many different fruits, vegetables, whole grains, seeds, nuts, and legumes as possible, variety. When you eat a variety of plants, you feed a variety of microbes, and that variety of microbes is now primed and perfectly positioned to do their job, whatever that may be from a gut perspective. I found something super fascinating in your book is when you talk about the diversity of fiber in the Hodza tribe, what have we learned from them, and who are they if you can briefly explain that? The Hodza tribe of modern day hunters and gatherers, they live in Tanzania in Africa, and so they don't have agriculture, they don't have money, they don't shop at stores, they hunt, and they forage, and so it makes for an interesting group to study because they're living the way that people lived like literally 10,000 years ago. What they've done when they've looked at the Hodza is that they find that they have a far more diverse gut ecosystem, literally 40% more diverse than the United States, the average American, 30% more diverse than people in the UK, and it's to the point, Darsh, that there are people who are calling for us to, because one of the problems that we have is that the Hodza are actually like contracting as a tribe very, very quickly, and the reason why is because they're not like living in isolation somewhere, they have made the choice to be a tribe, but some of the young people, they get born and they go, I don't want to be a tribe member anymore. So people are leaving the tribe, they're getting smaller, and there's been a call by scientists to say, we need to collect their stool specimens in the event that someday we need them. And so they're creating a biobank where they keep track of stool specimens from people from around the world, including the Hodza, including other tribes, but not exclusively native tribal people, but also including just people from around the world, because again, there's different microbiomes depending on your locale. There was an interesting study by the way you guys that just came out, where they analyzed like archaeologic poop, okay? And what was fascinating about this was not just that they were able to study poop from like literally thousands and thousands of years ago, what was fascinating is that people are starting to ask the question, because these studies are starting to come out now. People are starting to ask the question, who has the rights to this information? Because the information from an ethical perspective, the information that you find in this poop, may lead to pharmacologic development, maybe the solution that humanity needs in the future. So do we have the right as Westerners to go into the Hodza tribe and take their poop from them? Or is that an ethical violation? I got to tell you, these are not questions I think about on a routine basis, but that definitely is fascinating, yeah, I mean that is, yeah, I don't even know, Darsch, what are your thoughts, man? Sorry, I was muted there, yeah, I lost my words, I mean, it's super fascinating. And I think, you know, something we gather, and a question I have for you, Dutch, is if you know Walter Long was research, I'm sure. And he talks about how it's important for us, and you know, you mentioned how the U.S. and we've developed our own microbiome being where we are and the U.K. has its own. How important is it for us to eat what our grandparents ate, right? So my grandparents being in India, vegetarians, fresh cow's milk, buffalo's milk, very carbohydrate, heavy diet, you know, Walter Long would say, you should probably eat more of that food and actually forget the quinoa, that's more South American, what are your thoughts on that? Yeah, I think that's interesting. I think Darsch that, you know, Walter Long is playing off of a concept that, you know, it's the way that he's presenting that is almost more on a theoretical basis, but not yet completely proven, right? Like we haven't proven that because you're of Indian descent that you need to eat food that's traditional for your culture, right? We haven't proven that, but what's, but this brings us full circle on the idea or concept of bio individuality, which is that we are unique individuals, that when you study the gut microbiomes of identical twins, they only share about 30% of the same microbes. So they will be majority different and our response to our foods is unique and different as a result of those gut microbes. And this is a big part of what we're looking at with the Zoey project is looking at the, looking at our bio individuality. So let me give you an example, like let me say this first of all, I don't think that we will ever find in Zoey and the research that we're doing. I don't think that we'll ever find that eating junk food is better for you than eating greens or beans. Like I don't think we're ever going to find that, right? Because that just defies the laws of nature. Generally speaking, eating plants is always going to be the healthiest choice. But what's unique and different is that you might find that for your unique biology, there are specific adjustments or changes that you should make. For me, when I took my Zoey test, I personally found that tofu is not as healthy for me as I thought it was. But what is super healthy for me are lentils, asparagus, and avocados. So like I've ramped up my consumption of those things. So at the end of the day, it's all still plant-based. I'm not avoiding tofu. It's all still plant-based. But I do think that there is the ability for us to refine our process and walk into our bio individuality. And I would be curious if we did a study looking at whether or not there is a cultural connection in terms of that bio individuality. I think that would be really fascinating to bring that full circle. Yeah, I love that. I mean, it's all about trial and error, right? I know you haven't mentioned this today, but you previously mentioned that, although that plant-based is the approach for you, you don't always subscribe to that for all your patients. If somebody comes to you eating the Center of American diet, you're not going to completely flip them to 100% plant-based diet, right? And that's what I love. I do want to make this clear though, because I think people are going to be listening. They're saying, okay, fiber, fiber, fiber. Like, you know, how do I even get more fiber in your diet? I think that just so everybody is clear that you've previously mentioned that you don't even count the amount of fiber in your diet, right? Is that correct? No, you don't. I think I realized that, you know, I said 25 grams for women, 38 grams for men, and people, you know, it makes it sound like you should be counting fiber. I actually don't believe that you should do that. I think it actually gets back to, I believe it was Dars who mentioned this, the 800 grams per day of plants. So that, to me, is the exact same concept that I would promote, which is this. I emphasize plant-based diversity, eat as much variety of plants as you possibly can, going back to this idea, biodiversity within your diet, leads to biodiversity within your microbiome. And there was a study, the American gut project, where they showed that there was a single, most powerful predictor of a healthy gut microbiome. And that, the number one predictor of a healthy gut was the diversity of plants in your diet. Microbiome researchers universally agree that this is the critical piece. And in that study was 30 different plants per week. So, ultimately, from my perspective, stop counting grams of fiber, start counting varieties of plants, and make this a core dietary philosophy. Do it at every meal. Don't just go to 30 and stop. Every single meal is a challenge. Every single meal is an opportunity. And it's kind of fun to like, I'm a dad, I have two kids, my daughter's seven, my son is four. And like, they're old enough, I can challenge them. Bring it on, you guys, who's going to get more plants tonight? Let's go. Right? There's a lot of ways that you can make this really fun. And just rewire your approach to food, to make plant diversity, one of the core themes. And if you do this, I can assure you, you're going to feel better. You're going to reap rewards. It's just a question of what it is and how much it changes. I love that. I love gamifying the process, especially for your children, right? It's challenging to talk about nutrition with them because you don't want to restrict children necessarily. You want them to have a healthy relationship. So actually, I'm curious. So how do you, how do you have this discussion with them? I mean, will you allow them? I imagine they're pretty young to be preparing their meals completely. So how will they get more vegetables than you? Will they pick it out and will you help them prepare for it? What's your conversation like with them at that age, into help incorporate more vegetables in their diet and making that a habit? So when they're teenagers, that their palate is just adapted to that. Well, so it's kind of interesting because there's different phases of life. And being a dad, I see the difference between my seven-year-old daughter today, who I can have, like a pretty mature conversation with, versus when she was a newborn. And what's fascinating from my perspective is, first of all, I think that the palate of the baby starts before the baby is born. I think mom's dietary choices during pregnancy determine the dietary preferences of the child. And here's why I say this. Have you guys ever tried broccoli sprouts? Ultimus, have you ever had broccoli sprouts? Yeah. I haven't yet, but I keep telling my wife after reading your book at something when you start doing so soon. You got a sprout, man. You got a sprout. We'll have to do another podcast about sprouts because it's amazing. So broccoli sprouts are super bitter, super bitter. And when I eat them, I eat them and I embrace the burn because I know how good it is for my body. Good luck teaching that to a newborn kid, right? Like how do you say embrace the burn to a child? My son, when he was eight months old, was smashing broccoli sprouts by the fistful because my wife was eating them during pregnancy every single day. And so I'm convinced that taste buds start there. When it comes to your kids, I think again, it comes back to what is the stage or phase of life that they're in, but there's a lot of ways that you can gamify it with your kids. So if you get your kids cooking, they love that. You put options on the table. They love that. You give them dips, like different dips that they can go into. They love that. So it's just knowing your kids and what works best. Yeah. What about, so I think that for most people, what was it, some study came out, forget who the primary author was, but the 88% of Americans are metabolically unhealthy, right? And in terms of have one of the criteria of metabolic syndrome, just remember who the primary author was, but I'm pretty sure Dr. Beat, you're familiar with that one, right? So I think that it's pretty clear in terms of data as you've alluded to multiple times that when it comes to metabolic ill health, there's nothing better than vegetables, right? And the plant predominant diet is the way to go for that. However, there are some instances, you know, like IBD, where maybe they don't tolerate it as well. I've got a buddy here who's always just, it's either M&Ms or chips or this and that. It's because he has a history of Crohn's, he actually can't tolerate. So I mean, when is it, you know, what type of instances are, or is this diet not appropriate? So I would, what I would say honestly is it's not so much that it's not appropriate because it makes it sound like that's a hard stop and that you shouldn't even consider it. It's not so much that it's not appropriate. It's more so that there is a process to bringing this diet on board and that process will be different for different people. And the reason why ultimately I would describe it that way is this. And the person who has inflammatory bowel disease, if there was one nutrient that I would give them, it would be short-chain fatty acids. And I am of the belief that the epidemic of inflammatory bowel disease is in part due to our dietary fiber deficiency. But the problem is that fiber is entirely dependent on your gut microbiome for processing. We big strong humans don't have the enzymes to process fiber. The enzymes are called glycoside hydrolysis. We don't have them. A single cellular bacteria. There's one called bacteriaoidys, beta micron. That single cellular organism has over 200 of these digestive enzymes. The digestive enzymes are like tools for unpacking the fiber. And there are estimates that our gut microbiota may have 60,000 unique enzymes speaking to the complexity of fiber, again, like fiber is complicated. So we have a ton of these tools. And it's our gut microbes job to go and unpack the fiber using these tools. Here's the problem. You take the person with a damaged gut. There is no person with a more damaged gut than the person with inflammatory bowel disease. Their gut microbiome is literally on fire, right? So the person with the deepest dysbiosis, what should be 60,000 enzymes, they might have like literally 40,000. And they're missing the necessary pieces to unpack that fiber. Does that mean that they are incapable? No. The gut can be transformed. It can be healed. It can be made stronger. You can restore function. You guys aren't physical medicine and rehab. If I hurt my shoulder, what do I do? Well, I can tell you one thing. If I stop using my shoulder, I won't feel pain. But then I'll never be able to lift over the top of my head again. So how do I fix my shoulder? Do I go to the gym and grab 50 pounds and lift it over my head? No, I would make it worse, right? It's so obvious, I go and I work with you, right? And you give me a program. And that program involves like therapeutic, a therapeutic approach that is back to the basics. We start with small stuff. And we're just trying to get to the point that I can lift my arm out at a 90 degree angle. And then a little bit more. And then a little bit more. And one day, you're actually able to lift your arm over your head again, which means you're ready now to take a one pound weight and lift that over your head. And you built, right? So this is what training your gut is about. If you take the person with inflammatory bowel disease, they have the deepest dysbiosis that exists. I am not exaggerating when I say that it could take them more than a year to heal their gut and restore the function that they need. If you take these fiber rich foods, take black beans, for example. If you introduce them in small amounts, you are going back to the basics. You will get the enzymes that you need. You will grow stronger. And what starts as a small amount becomes a moderate amount. And what becomes a moderate amount can become a normal amount, but it may take months for you to do that. And so you just have to understand the process. If you don't know what you're doing, then you're just going to eat a ton of food. And you're going to be like, oh crap, I feel miserable. That's because you just way overdid it. That's conceptually the same as having a bum shoulder and going into the gym and just grabbing weight and lifting it. Mm-hmm. Yeah. You're talking about this calming down the inflammation and several different diseases and talking about short-chain fatty acids. And earlier you talked about chia seeds. And I know you previously mentioned omega-3 fatty acids. We know that they have a very strong cardioprotective effect and the data is really promising when it comes to neuroprotective effects as well, particularly for EPA and DHA. One of my issues is with a plant predominant diet or not getting any marine sources, how do you go about getting the EPA and DHA? Because again, my understanding might be limited on this, but our body does not do a great job converting ALA, right? And that's what you're getting from walnuts and chia seeds and all those types of things. So what are your thoughts about that? And I know you said, are you 100% or every now and then will you introduce some marine foods as well? Well, so I'm 100% and yes, I will consume, like if we're including sea vegetables, then yes, I will consume those. But I think that the important, but your ultimate question is an important question. And we need to unpack this because I want people to understand the details here. Because I think that omega-3s are a nutrient of concern, like after fiber, this might be where I go next. And so the issue is that first of all, we are problem, like lining up the problem. We have a diet that's very deficient in omega-3s. There's another form of polyunsaturated fatty acids, which are omega-6s. Both omega-3s and omega-6s are essential fatty acids, meaning that we have to get them from our diet. We are incapable of producing them ourselves. Omega-6s are actually essential, like we need them. Here's the problem. They are found in vegetable oils, like canola oil, which is in all processed foods, which makes up 60% of the American diet's calories. And we are getting a wild, we excessive amount of omega-6s in a completely inadequate amount of omega-3s. The ratio is important. We want a ratio that should be close to one to one, very realistic. Should be about four to one of omega-6s to omega-3s. That would be a healthy ratio. We as Americans are like 15 to 18 to one, so we're way off. Now, ultimately, you brought up the issue of ALA, DHA, and EPA. DHA and EPA are the long chain omega-3s. ALA is the short chain. Let's separate these out for a quick moment, because I think there's a couple teaching points here. ALA, not for you, just like kind of me, I'm going into chief resident mode here, and I'm talking to the people who are at home hanging out with us. Love it. ALA is a terrestrial omega-3. It comes from land sources. Chia, flax, hemp, walnuts, all have omega-3s. Legumes have omega-3s. All right. DHA and EPA come from the sea. Are DHA and EPA produced by Sandin? No. They are not. There is no animal that produces omega-3 fatty acids. All omega-3s come from plants. The salmon consumes algae, or the krill consumes algae, and then the salmon consumes the krill. The algae is the source of the DHA and EPA. The salmon stores the DHA and EPA in its fat. We consume the salmon, we get the DHA and EPA. There is no question that consuming salmon, or sardines, is an effective way to get this nutrient of concern. There is no question. All right. But from my perspective, there is a problem. The problem is that we have 8 billion people on this planet. We had 2 billion in 1900. We had 1 billion in 1800, and we're about to be 11 billion in the next 30 years. Our ocean is radically different than it was even when you and I were kids, and we're not that old. Talk about 100 years ago. Completely different. I'm not even talking about sea-spiracy, which I did enjoy the movie, but I'm not talking about sea-spiracy. I'm talking about this ocean is different, and ultimately if we all go pescatarian, 8 billion people going out of 11 billion people, I can assure you there will not be enough fish in the ocean by 2050 for that to happen. It's just not possible. And we don't need to. We don't need to. It's not a requirement. The requirement is the omega-3. The source of the omega-3 is the plant, which is the algae. And it's very easy to supplement the algae oil, and you can make a compelling argument, even removing the scarcity issue, even removing sustainability from the equation. And just looking at the fish, we have polluted our ocean. The fish have microplastics that didn't exist 50 years ago. There is the accumulation of heavy metals, like mercury, that is occurring as we move up the food chain towards salmon, less of a concern with sardines, by the way, and sardines are also more sustainable. But anyway, that's my point, is that we can get our omega-3s. We can get them from algae-based supplements, which is what I do. And the other thing that I want to add real quick and important teaching point, getting back to omega-3s omega-6s, is that this ratio is important because the omega-6s compete with the omega-3s for conversion from ALA to a long chain form. So when we excessively consume omega-6s, that is actually the reason why we are struggling to produce the omega-3 long chains that we need. So an important part of this equation, like, yeah, each year in flax and ham, please, but cut back on your omega-6s and get to a healthy ratio. Yeah, no, I think that's super important that what you just brought up in terms of, it's a ratio in the end, right? It's not things that were necessarily counting, but it's a balance. And see Spiracy, Ultima, I'm telling you, man, you got to watch it. It's interesting, it's compelling, it's good. So that should be, how are you doing on time here? Are you okay to hang with us for a little bit longer? Just have another, like, top or computer. All right, awesome. I would want to- We got two more hours left or we're going to be doing it. We're going all nighter, I thought. No, just kidding. Yeah. You guys are going to have to do that. I'm too old for that. I thought you said it's like college again, huh? You feel like you're in your college body. Oh, man. All right. So I want to bring up intermittent fasting, where there's just concept of time restricted eating. So many people are doing it, and it's becoming a lot more popular in terms of resting the gut. What are your thoughts on fasting? Are there any great mechanisms behind it that show, or any good data that show that this can help our gut health? We need more data, we need more data. Most microbiome experts do believe that this is completely legit. Let me break down the narrative of how we're looking at this. So if you think about all life on this planet, all life, including the archaea, four billion years ago, there is one rule since day one of earth, one rule that has been maintained as true from the very beginning to today, and all life evolved under this one rule. The sun goes up, the sun goes down every single day. And so if you look at it and think about this, it's like mind blowing for me to think about this. Maybe all our products of the sun, right? We need our vitamin D. That's a huge part of the way that our body functions. We need our vitamin D as humans. And our energy comes from carbohydrates, which is plants. And the plants exist because of the sun, right? Our gut microbes, I'll stop being philosophical and zoom in on the gut microbes now. Our gut microbes evolved under the same circumstances. And what that means, what I'm saying is that they have a circadian rhythm just like us. When I say circadian rhythm, what I mean is that we have basically like oscillations in our physiology that occur on a 24 hour cycle. So for example, like it's in the evening here right now. So like my melatonin levels are rising. And that affects the way that my body works. If you take a person, right, Darsh, we take you. Sure. I give you literally the exact same meal at 7 a.m. or 7 p.m. It's literally the exact same meal in every way. Your blood sugar will spike at 7 p.m. relative to that 7 a.m. meal. Because we know that our circadian rhythm, our insulin, our insulin sensitivity is diminished as the day goes on, right? So the point is this, everything works on a circadian rhythm, including our gut bugs. We need rest. We need to observe our circadian rhythm. They need rest. And we need to observe their circadian rhythm. Very nice snacking, not good for the gut bugs. They need a break. The ideal way to do this from my perspective is quite simple. Not only is it time, like taking a break from eating solid food, but it's also timing. Having an early dinner, ideally before 7 p.m. And then make a hard rule. Like if you're going to have dessert, so be it, have your dessert. But then make a hard rule, only water or herbal tea after dinner. And that's it. Go to bed and wake up the next day. And if you wait until 7 a.m., it's been 12 hours and you've been resting your gut. And that's pretty good. Yeah. Yeah. And Dr. B, what I'll say is that there's actually a study that was recently published in Nature Communications. I was scanning literature this morning and I saw this. I think the primary author was Mayfield. Are you familiar with that one? Well, basically, I'll just give you a quick rundown. Yeah. Yeah. So for the listeners at home, this was a randomized control trial, a 12 week study where they had 71 patients with metabolic syndrome. And they basically split them down the middle in two groups and they had a fasting group. I put that in quotes because truly, it wasn't a complete fasting, not complete restriction from food. It was more like an FMD protocol. Basically, they had data two days of vegan diet followed by veggie juices for that whole week or the rest of the five days. And then they did the same diet for the next 11 weeks as the other group, which was the dash diet. And they looked at blood pressure, looked at body weight, BMI, the Homa IR, which is kind of just a marker for insulin resistance. And what they found was that both groups had an improvement in all those markers, all the biomarkers. But again, FMD or fasting group had a significantly or statistically significant more improvement in terms of all the numbers. So again, I think that as you mentioned earlier, the literature is really young on this. But I just thought that was pretty promising. Yeah, I think the bottom line, I think the bottom line for people who are curious about this, the bottom line from my perspective is that I don't think that you're going to hurt yourself by setting up reasonable like time restricted eating protocols, where it's like 12 hours or 14 hours of fasting, something of that variety. I think that's completely fair game. I do think that people potentially take it too far where it's like, they think that this is the backbone of human health. It's not, and you know, you can extend things out like 18 hours, 20 hours. And I think that's kind of pushing it a little bit, because I think at some point, everything in life is like, you guys are residents, think about oxygen, right? We need oxygen to live, but 100% oxygen is toxic to the body, right? Every single thing that exists, there's a point at which you take it too far and it becomes inflammatory. It's like, there's a sweet spot. And then you can go to the point where you actually hurt yourself. And so I think that that's true with fasting as well. I think it's just set reasonable expectations for the fasting. And then I think really what it is is look for other low hanging fruit. Don't just push, push, push on the fasting, look for diet changes, look at sleep, look at exercise, look for opportunities there. Yeah, everybody's looking for the magic pill, right? Everybody wants the one thing that's going to make it, right? And the answer is never sexy. So you got to do diet and sleep and exercise and eat more vegetables. And at this point, if anybody's even listening, and we don't want to be reductionist here, but I do think that something you mentioned earlier is pretty important, right? If we're going from the standard American diet and consuming in the upper end, 22 grams of fiber a day, and what you're advocating for is significantly more for that. Although you mentioned we're not counting fibers, fiber is just coming along for the ride, we're just counting vegetables, right? 30 is the number, more is even better. If somebody were to come to you in clinic, right, you also said that, hey, you got to start low, go slow, right? That's kind of, that's kind of the model there, right? So how would you start them? Are there some superstar foods in those 30 that you try to go for a weekly basis? You would say, hey, start here. This is, you know, this is going to give you the most bang for buck. And then we'll start incorporating, we'll do maybe five in three weeks and maybe we would attend, if somebody's doing two vegetables a week, like where do you start with them? Well, there is no bad, there is no bad plant, right? And we, and the other thing too is like we tend to, when we say plants, we all sort of assume vegetables, right? But let's not forget, we're talking about nuts, seeds, whole grains, legumes, in fruit, and they're all fair game. So, you know, I think from my perspective, depending on who I'm talking to, if it's more of a motivation thing, then from my perspective, where I start with them is one meal and start with something that you love. And just try to make a plant based. So that's the, like start with the type of food that you really enjoy and then grow from there. If it's a person who has a sensitive gut, I would not start with a raw diet. I would not start with a salad for their first meal. To me, you actually want to take advantage of the fact that by cooking your food, you are actually making it more, you are making it easier for your gut to process it. You're effectively pre-digesting it in a way. And so, you know, to me, like soups are a great place to start for the person who has a damaged gut. In my book, I had a recipe for what's called biome broth. Biome broth is my response to bone broth. There are zero studies that say that bone broth actually heals the gut. A lot of claims zero studies. The only study that I've seen on bone broth suggests that when you put bones into broth and you boil the water, you start pulling the heavy metals out of the bones and it can become potentially unhealthy. So, but what is healthy is fiber and polyphenols. And so biome broth is a great place to start because it tastes good, it's soothing for the gut and it has the fiber and the polyphenols that are good for our microbiome. Dr. B, I got to ask you this because I know how much you love poop. I know you're obsessed with it. But currently, you're doing something called a blue poop challenge. What's that all about? Blue poop challenge. It's kind of, okay, so I think this is kind of cool, Zoe, and I've been talking about them a lot. The reason why is because I love the science. And they just published a paper in gut, which is the top gastroenterology journal, my field, I'm a gastroenterologist, the top gastroenterology journal in Europe. And what they showed is that if you have people eat two blue muffins, the blue dye does not get absorbed, so ultimately it will pass in your stool. Now, it doesn't have to be muffins, it just needs to be blue dye. And ultimately, what we're trying to collect is transit time. When they looked at this, this was actually more accurate at predicting characteristics within your gut microbiome, including diversity, including specific species that were likely to be present, and even looking at certain cardiometabolic factors like your blood sugar and your blood lipid response after a meal or your visceral fat levels, they were actually able to correlate transit time from when you consume the muffin to when you poop blue. And so it's quite fascinating to think that you could eat two blue muffins and gather information about your gut health, your gut transit time, your gut microbiome, cardiometabolic risk, visceral fat by eating muffins. And so they started this campaign just for fun, which is like, you know, this is part of it is, look, this is science, but part of it is like, this science is crazy, what are we talking about? Okay, fine, let's just put it out there and see what happens, let's eat some muffins, folks. Why not? I do want to follow up on this though, because I've heard several people talk about this that, you know, I don't know if at any point this was true or not, that we should be, you know, having a bowel movement almost after every single meal. And that gives me some pause, because I don't really know how we'd be able to do our jobs, especially in residency or go through rounds if I had to do it, you know, while I'm eating. So what are your thoughts about that? Because, you know, when you talk about transit time, so I'm wondering if faster transit time means, quote unquote, a healthier gut, is that what the implication is there or like, what does that tell us exactly? Ultimately, first of all, having a bowel movement should be one of the highlights of your day. And if it's not, and I don't mean this directed at you exclusively, that would be kind of creepy and weird. Yeah. I just think for everyone, like having a healthy bowel movement should be fun, it should be pleasurable, and you should look forward to it. And if you don't, you need to see someone like me. That's a gastroologist. So the idea of having three bowel movements a day, it's probably true. If you actually look at our ancestors, like to take the hudza, for example, they consume 100 to 150 grams of fiber per day. When you consume fiber on that scale, and there are multiple, by the way, studies from across the globe where they look at tribal people, and they're all unique and individual, but many of them were consuming fiber on the scale. If you consume fiber on that scale, you're going to be pooping. I can't get a poop like once every five days, you're going to be pooping. So I don't know that we need to focus too much on actual, like how many times a day do we go, at the end of the day, what I look for in my patients is not a number. I look for, do they feel like they're in a good rhythm? Do they feel like they are completely emptying? And because if they do, and they're not having digestive symptoms, like it's amazing how the gut falls into alignment, and my job becomes easy, if I can get my patients into a rhythm. Rhythm is just as important to the gut as it is to the heart. And so to answer your question, like what is normal from a bomb movement perspective? Frankly, I don't know that it matters that much, right? Like I want to take a person who's pooping once every three days and say you need to make radical changes to your diet or to what you do based on that information alone. I think at the end of the day, we should all be looking to optimize our diet and enhance our gut health because that's going to give us downstream benefits and that's part of what they're looking at in the study and tapping into. Love it. Super cool, super cool. Well, Dr. B, I just want to tell you, fiber fuel is an absolute hit, right? I loved it. I think it's obvious when you go on Instagram, how many people are tagging you in the book, of recipes you have in there, super phenomenal. And I think the biggest thing about it, too, is that when you look at these nutrition books, a lot of them become dogmatic, and that's not what you're doing. You're putting the science in there, you're putting the research, and you're just trying to advocate how we can optimize our lives just by introducing more fiber and more plants. So thank you so much for what you do and how you educate people through your platform, just being such an awesome guy coming on here and having a cool conversation. But what's next for you? What are your upcoming goals? Do you have more books in the pipeline? What's next? So obviously I'm excited about the work that I'm doing with Zoe being on the scientific advisory board. There are some really cool things that we're working on behind the scenes in terms of clinical studies that I'm going to be a part of. I'm really excited. I mean, that's a dream come true for me. I almost feel, to be honest with you guys, it's almost unfair. Because I am a big believer in fairness, and whoever puts in the work gets the reward. And I realize that I've worked very hard, but it's kind of unfair because I'm sitting in the scientific advisory board with these people who are lifelong career researchers from Stanford and Harvard, and then I roll in and I'm like, hey, what's up? But I'm really excited about the work that we're doing there. I really think that it's a game changer. What I dig about it is that the whole program, if people participate in it, it's beneficial to them on an individual basis. But it also is this concept of citizen science, which is that if you participate, you are contributing information to the greater population, and then we all derive benefits from that. And so I kind of dig that. I think it's really fun. I got a lot of cool stuff that's been happening. This year has been insane. My book came out May 12, 2020 in the middle of the pandemic, and things have been just like happening. And it's like just when you aren't expecting it, you get a phone call from someone and another thing happens. So I have a lot of really exciting things in the pipeline that I'm not yet ready to make public. But if you pay attention, you follow me, then brace yourself because I got some stuff coming. I love it. I'm super excited for all the things that you're going to continue to do that, Dr. B. I also want to thank you for taking time out of your busy schedule. As you mentioned, you've got a busy practice. You have children who probably want to spend some time with you tonight. But instead, you're here, educating a couple of punks like us. So I really appreciate that, and I appreciate you just coming on here, inspiring our listeners as well. Sure, people might listen to this, and maybe they want some to learn about more plants and how to incorporate that. Maybe they just want to learn how to take epic dumps. How do they find you so they can do that? Oh, man. You just got me with the epic dumps there. I love that. All right. So you guys can find me on Instagram as the gut health MD. I'm on Facebook as the gut health MD. I have a website, theplantfedgot.com. Very proud of it. I have a free seven day challenge that people have been really digging, again, completely free. I have an email list where when new research studies come out, basically like, it's hard for me to go to Instagram and condense everything I want to say into Instagram post. So I'll put it out to my email list, and I'll do it now. So like breaking news, here's a hot new study, boom, for you guys. That's my email list, and I have a course at my website, theplantfedgot.com. You can check that out. It's a seven week course. My book is called Fiber Fuels, and last thing, if people are interested in the Zoey thing, you can learn more by going to join Zoey.com, Backslash, Dr. B, and the beautiful thing there. Don't tell, like, what the hell, tell everyone, this allows you to cut the line. So Zoey has like a several thousand person wait list, but because I have like a friends and family code, you can cut the line. That's right. This is all the more reason people need to listen to this podcast right here, exclusive, exclusive. Well, thank you so much. We're going to link all that in the show notes, so people can easily access that. Now, here is the last question that we'd like to ask all our guests, and might be the most important one, but although we've been talking about it for two years, so maybe you could just sum it up. How do we add the health back and health care? I should have prepared for this question. Honestly, honestly, if there's only one thing, we have to listen to our patients. I think it's really that simple. If you listen to your patients, they will show you the way, because they'll basically tell you what they need, and then we can give them what they need. I love that. Love it. Awesome. Perfect way to end it. Thank you so much, Dr. B. Appreciate it. Thank you. Thanks, guys. Take care. All right. Like I said, I hope you guys all took away so many knowledge bombs from that. I think it's safe to say that in 2022, we should all make it a goal to take epic dumps. At least consistently, we should be having epic dumps. So cheers to that. But really, I want to make a call to action for everyone here. One little thing is that with the holidays approaching, obviously, we're going to have a lot of temptations in front of us, right, in terms of food, with pies and junk food and sweets and nice drinks. And that's okay. It's a time to celebrate and rightfully so. But let's make it a goal to at least plan ahead of time. If we know we're going to parties or meeting up with guests or going to have an extravagant dinner, let's keep ourselves in check. Let's keep ourselves consistent. Let's make the right food choices as much as we can. And of course, let's target that fiber, right? Fiber is so vital, which I hope, you know, that was the one thing Dr. B loves to highlight. It's so vital. All right, you guys. And with that, the disclaimer, everything in this podcast is for educational purposes only. It is not constitute the practice of medicine and we are not providing medical advice. No physician patient relationship is formed and anything discussed in this podcast is not represent the views of our employers. We recommend that you see the guidance of your personal position regarding any specific health related issues. And if you've been with us again for over the year, huge thank you and if you're new and you're loving the content, subscribe and please share any of the episodes that you found in the last year to be helpful with your loved ones. I'll see you next week.