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This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

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

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

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

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

Mitch: Are we talking about poop again?

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

Mitch: I mean, he's here.

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

Mitch: I know. He's back.

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

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

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

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

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

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

Dr. Pohl: We got that done.

Mitch: Good. Thank you.

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

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

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

Scot: What is the microbiome then exactly?

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

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

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

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

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

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

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

Scot: And that's where the microbiome is?

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

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

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

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

Mitch: Is anyone else feeling itchy?

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

Mitch: Yeah, with another gross-out episode.

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

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

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

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

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

Scot: Yes, please.

Troy: Mitch, did you catch that?

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

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

Dr. Pohl: We use a parent.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mitch: Kimchi or whatever.

Dr. Pohl: Absolutely.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Pohl: Absolutely.

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

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

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

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

Dr. Pohl: Absolutely.

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

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

Scot: Okay.

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

Scot: Do you hear that, Mitch?

Mitch: I hear it.

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

Mitch: On it.

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

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

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: Oh, it's the big 100th episode. And everybody has been asking, "Guys, what are you going to do?" Mitch and Troy keep nagging me. They're like, "Come on, Scot. What are we going to do? We've got to do something special for the 100th episode."

Troy: That's a pretty good impersonation of me right there.

Mitch: I don't know about nagging.

Scot: And we have something special today. So this is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men and men's health. He brings the MD to the podcast, Dr. Troy Madsen.

Troy: Scot, I can't believe it's 100. And I can't believe we're actually still talking to each other after 100 episodes.

Scot: The BS, that is my job. I bring the BS to the show. My name is Scot Singpiel. Mitch, he brings the mics. Welcome to the show, Mitch.

Mitch: I bring the mics. A hundred episodes and I finally get a little intro. I love it.

Scot: Yep. And our guest today is Dr. John Pohl. He's a gastroenterologist. Welcome to "Who Cares About Men's Health."

Dr. Pohl: It's great to be here.

Scot: All right. So before we get to the main show, I have a question for you, Dr. Pohl. Can I call you John?

Dr. Pohl: Please do.

Scot: All right. I have a question for you, John. How do you know if somebody runs marathons?

Dr. Pohl: They talk about it.

Scot: Yeah, that's right.

Troy: I was going to say there is no way of not knowing because everyone has a way of slipping it into a conversation in some way or another, like, "The weather is great out today. This is the exact weather I had when I ran the San Francisco Marathon. I felt just like this."

Scot: Yep. They'll tell you, all right.

Troy: They'll tell you.

Scot:Don't worry about that. Yeah. One of the things we're going to celebrate on our 100th episode is the fact that Troy had a personal best time in his most recent marathon. And I just find this amazing. He broke the three-hour mark. Congratulations, Troy.

Mitch:Nice.

Troy: Thank you. Thanks, Scot. Thanks. Yeah, it was a great race. I loved it. It was a cool experience. I did not go into it expecting to do that, but I figured it was kind of a fast course. It was a downhill course. I didn't really think I was going to do it until I had a mile left. And then I thought, "Wow, I'm going to do this." And coming around that corner, it was a cool feeling, like, "Wow, I broke three hours."

It's kind of one of those things you think about as a marathoner. I was thinking about Boston. I had the chance to do that. And then to do this, yeah, it was a cool experience.

Scot: So you beat your previous personal best by like 10 minutes?

Troy: Yeah. Ten minutes.

Scot: That's also just insane. Congratulations.

Mitch:Wow.

Troy: Thanks, Scot.

Scot: How many miles an hour are you running on average to do that? John, do you have any idea how fast you have to go to break three hours in a marathon? Twenty-four miles? Twenty-six miles? Twenty-six miles.

Dr. Pohl: You were going like 4.5 miles per hour, right?

Troy: Yeah.

Scot: Were you doing 4.5 miles an hour?

Troy: Well, it's a 6:48 mile. I know that. I don't know exactly the miles per hour. So it'd be a little more than 4.5. Yeah, it'd be more like probably eight and . . .

Scot: For 26 miles.

Troy: Yeah. Because you figure it's just under 3, so 8 times 3 is 24.

Dr. Pohl: Oh, that's right. It's 26 miles.

Troy: Yeah. So it'd be like . . .

Dr. Pohl:That's like 8.5. Yeah.

Troy: Yeah. So maybe 8.5 or so. A little over 8.5.

Scot: Hey, Mitch. When was the last time you ran 8.5 miles an hour ever?

Mitch: Never in my life whole.

Scot: For any period of time.

Mitch: Zero. Zero time.

Scot: Zero time. All right. So let's get to the show. For our 100th episode, guys, I've kept it a little bit of a secret. You wanted something big, you wanted something special, and I thought for a long, long time about, "What is the most appropriate way for us to celebrate our 100th episode of this podcast 'Who Cares About Men's Health'?" Having Dr. Pohl on, who's a gastroenterologist, to talk about poop.

Mitch: For real?

Scot: The 100th episode of "Who Cares About Men's Health," we are giving you the poop on poop.

Mitch:Oh my god.

Troy: That's right. That's what we do.

Scot: Do you think that's appropriate, Troy? Mitch does not think it's appropriate. He's very disappointed.

Troy: Mitch does not think it's appropriate.

Mitch: I don't know why. Of all the health things to talk about, of all the true crime things that I read and listen to and whatever, there's something about poop that I just can't get over.

I'm excited. A hundred episodes. Let's do this.

Scot: All right. The first thing I want to know is can our poop tell us something about our health? And what would we be looking at? To me, I think it would come down to three things, right? Well, two things: how it looks and how it smells. Are there other considerations?

Troy: Maybe how firm it is, the consistency.

Scot: All right.

Dr. Pohl: Yeah. I think that things you would think about would be how hard or soft it is, how frequent you're having it. And then, of course, you're asking about smell, and that can be a little difficult because when people tell me their poop really stinks, I'm sometimes stuck because I kind of go back to the baseline belief that all poop stinks. So maybe I'm missing something. But there are some situations where it does stink.

No, but seriously, you're exactly right. I mean, your fecal matter is loaded with just billions of bacteria, and there is a huge correlation between that and health. A lot of it we've only realized probably in the past 20 years, that there's such a correlation. And not just with intestinal health, but overall body health, which is really fascinating.

Troy: I will tell you, John, as you're talking about this, I've had more than once . . . Number one, people come in and show me pictures of their poop.

Dr. Pohl: I promise you I've outdone you.

Troy: This one is even better. I had a patient come to the ER, who came on a bus, and had multiple mason jars filled with his poop samples suspended in water. Was carrying this in a bag. I can just imagine these things rattling around on the bus and then had them all displayed in the room for me to look at, because there was something to it and I had to see it. I don't know if you've outdone that one, though. You probably have.

Dr. Pohl: Yeah. I mean, I've had people bring in several pounds' worth of diapers for me to look through.

Scot: Wow.

Mitch:No.

Scot: Well, I mean, if you think there's an issue, what else do you do?

Troy: Yeah, a doctor has got to see it. Has got to see it firsthand. I usually tell people, "Just describe it. I think that's adequate." But some people kind of take it to the next level.

Scot: Is that true, Dr. Pohl? I mean, if I went to a gastroenterologist because I thought I had an issue . . .

Dr. Pohl: You don't need to bring me your poop, Scot.

Scot: Okay. Just describing it would be enough?

Dr. Pohl: Yes, that's fine.

Scot: All right. So our poop can tell us something about our health. Let's talk about what it looks like first. I've heard a lot of times if you take a look in the bowl, that could tell you generally how you're doing.

Dr. Pohl: So you want me to tell you what poop looks like?

Scot: I want to know if . . .

Dr. Pohl: Because we can start really basic here.

Scot: Yeah. Actually, hold on.

Dr. Pohl: Guys, you just may need to help me here. It sounds like Scot is having an issue.

Troy: Yeah, Scot. Let's hear what's going on.

Scot: All right. Mitch and Troy, I'm going to send you an email. Okay?

Troy: I know what you're going to send me, by the way, but . . .

Scot: Oh, what am I going to send you?

Troy: It's going to be the . . . I'm blanking on the name of the scale, but it's the scale that shows the various types of consistency of poop.

Scot: And what's that scale called, Dr. Pohl?

Dr. Pohl: It's the Bristol Stool Chart.

Troy: That's right. Bristol.

Scot: And it's from England, right?

Dr. Pohl: Yes. And as a friend of mine once said, "What was going on in Bristol to make them come up with this chart?"

In actuality, there's the funny side of this and the serious side of this. The serious side is it's very helpful telling if someone's having diarrhea. So it's 1 through 7 and it's been kind of used clinically to . . . I mean, it has things like constipation and stuff, but to really help people determine if someone really is having diarrhea, that's what it's been clinically modified for. I think it does a pretty good job of 1, 2, 3, 4, 5, 6, and 7.

Scot: Yeah. So number 1 is severe constipation, which looks like deer droppings. And then 2 is mild constipation described as lumpy and sausage-like.

Dr. Pohl: Kind of like Oktoberfest.

Scot: Number 3 is normal. So there are two types of normals. I guess I didn't know this. A sausage shape with cracks in the surface, that's normal, and so is a smooth soft sausage or snake.

Dr. Pohl: It's like M&Ms or peanut M&Ms.

Scot: Number 5 is lacking fiber. That's soft blobs with clear-cut edges. So unlike the deer poop, it . . . How does that differ actually? I don't understand what they mean by clear-cut edges.

Dr. Pohl: That's the one thing that I always find somewhat humorous about this stool chart. It has a very, to my opinion, English description of the poop. And I'm not exactly sure. I would assume that soft blobs is all you need to do, but obviously soft blobs with clear-cut edges. I'm not exactly sure what that means.

Scot: All right. And then mild diarrhea is mushy consistency with ragged edges. And then severe diarrhea is liquid, no solid pieces at all.

Dr. Pohl: Right. And again, I don't know what ragged edges . . . I mean, that's terrifying. But yes, we'd use that.

Troy: So it sounds like, though, you don't want the ragged edges, the fluffy pieces, and you don't want the watery.

Dr. Pohl: Right.

Troy: And you don't want the severe hard lumps or the sausage shape, but lumpy. Kind of that middle ground is where you want to be.

Dr. Pohl: That's exactly right. So if you're wanting to have a normal bowel movement, just from a simple medical perspective, you really want a 3 or a 4. And so my rule is you should be pooping once a day. And if you're having too much constipation, we can talk about that in terms of safe laxative therapy. And if you're having diarrhea, make sure it's not an infection or something more serious.

And then in the adult world, obviously, you want to pay attention. If you aren't having issues with colon cancer, which you can see with persistent rectal bleeding. Sometimes it can be a very pencil and small-shaped stool as you're trying to go through a cancer area. Sometimes if people are having a hard time and they're pooping Type 1s, often it's constipation, but if it's soft and it looks like little, tiny, hard lumps, you should worry about rectal cancer as an example.

So we should take it . . . I mean, we joke about poop, and as a gastroenterologist probably my entire life is joking about it, but you do want to pay attention to what you're seeing.

Mitch: I guess when we're talking about the consistency, is this on a day-to-day? How consistent, how frequently should we see things that, say, jump between the chart?

Dr. Pohl: You should have a notepad and a calendar every day.

Scot: And you always have your phone on you so you can always take a picture.

Mitch: I'll take a bunch of pictures for you guys.

Dr. Pohl: Yeah, honestly, my rule is a normal bowel movement is a soft, not diarrhea-type stool once or twice a day. When people ask me how often, you should try to shoot for once a day. Some people really don't. But yeah, you want to do that.

And then just kind of pay attention. The biggest issue that we would have in this country, just because of dietary issues, is problems with constipation, which may affect as many as one in every eight Americans. And that's actually the biggest thing that we often see and probably you see in the emergency room setting. Number one reason I see kids in my clinic. So these are things to keep in mind.

And then did you know . . . I think a sloth, by the way, poops every eight weeks.

Mitch: What?

Troy:Wow, every eight weeks?

Scot:Wow. Imagine the kind of money you'd save on toilet paper.

Troy: Seriously.

Scot: That would be amazing.

Dr. Pohl: Yeah. It's actually the animal model that's often used for constipation because they just poop so rarely.

Scot: Wow. All right. So as far as shape goes and consistency, I'm looking at this chart. It looks like it's either something is causing some constipation, which I'd want to eat more fiber at that point. I mean, is that what's causing that? Or are there illnesses that would cause that constipation?

Dr. Pohl: Well, the vast majority of the time, it's just constipation, which is an issue with both the movement of your colon from the top of your colon to your bottom and just also how much water and fiber you have in your stool. So that's the most common reason. When you live in a dry climate, that's something you have to kind of pay attention to. So in states like Utah, that's a problem.

And of course, fiber does help quite a bit in that setting. We are Americans. Americans are not the best about fiber, and sometimes just working on things like taking a very safe over-the-counter stool softener is very effective in most settings.

Troy: And do you recommend fiber supplements as well?

Dr. Pohl: I think fiber supplements are never a problem, but there are very, very safe over-the-counter stool softeners. I typically don't use stimulants. I try to use more like what they call stool softeners or osmotic laxatives. Osmotic means it just brings water in from your body into the colon to make it softer. Things like Milk of Magnesia, MiraLAX, there are lots of different things that are out there. Very, very safe. And those tend to be extremely effective.

Scot: So if I'm dealing with constipation, more water, perhaps more fiber in the diet. I would imagine people that are on the Atkins diet probably experience constipation, people that might . . .

Dr. Pohl: They do have a lot of problems. Yeah. That's exactly right.

Scot: Or fast food. If you eat a lot of fast food, you're not getting a lot of fiber a lot of times.

Dr. Pohl: Right. Oh, absolutely. Diet is a big part of it. And then also exercise really helps quite a bit as well. And I'm not talking that you have to be a marathon runner. Troy, as you probably know, people who are long-distance runners can have some problems with diarrhea, which we can talk about.

Troy: I know all too well.

Dr. Pohl: Yeah. But just getting some good walking exercise in. I'm not talking about weight lifting, that doesn't really do it, but cardio really can help regulate your bowel movements.

Scot: All right. And then on the other end of the scale, the other end normal, we've got the looser, which is soft blobs or mushy consistency or diarrhea. Are those generally reasons to be concerned, or are there dietary things that could impact that just temporarily, and if you stop eating those things, everything is good again?

Dr. Pohl: Yeah. I mean, as a pediatric gastroenterologist, I worry quite a bit more about diarrhea because I want to make sure I'm not missing a malabsorption syndrome or an infection or something inflammatory like Crohn's disease.

Now, honestly, the most common things I see is what you would see in the setting of irritable bowel syndrome. So irritable bowel syndrome, let's say you get anxious about something and your stomach hurts. Very common. Some people get constipation with their abdominal pain and irritable bowel syndrome. We call that constipation-type. But some people get diarrhea-type and they get anxious and their stomach hurts and they have some diarrhea.

If you know there's nothing else going on, you can offer over-the-counter medicines that decrease diarrhea, such as Imodium type products.

But you do need to pay attention. So the times I get very worried if it's diarrhea associated with weight loss, diarrhea with blood in it, especially what we call nocturnal stooling. If you have to get up in the middle night and poop and have diarrhea, that's extremely concerning for something else going on.

Food products can do it. What I see quite a bit in children is if they drink a lot of juice or eat a lot of fruit, they get what's called nonspecific diarrhea of childhood, or it's also called toddler's diarrhea. And they basically just have too much carbs and they just have a very foul-smelling stool that actually is fairly acidic and can cause a diaper rash. So that's really not something we see as much in adults, although you can see that sometimes with people who drink too much alcohol as an example.

Scot: I was going to say sometimes after maybe having a few more beers than I should, like the next day, I might notice things are a little softer than normal. That is being caused by the alcohol? Or sometimes if I eat too much junk food.

Dr. Pohl: Oh, absolutely.

Scot: Like the week leading up to Halloween when you got the junk food in the house because you're going to give it to the trick-or-treaters, and then you end up eating it all before Halloween and have to go to the grocery store and buy more.

Dr. Pohl: Yeah. The thing that I'll see is teenagers who eat a large amount of chips with a large simple carb load, they'll do the same thing. Are you familiar with the things called Takis? Are you familiar with Takis at all?

Troy: Like taquitos?

Mitch: No. They're gas station food.

Troy: I was going to say Mitch is familiar with taquitos.

Mitch: I do know taquitos.

Dr. Pohl: So they're a type of chip and they have a lot of spicy stuff in them. They have one called Fuego, which I think is fire, and one called blue heat. And besides getting all the carbohydrates, all the chemical stuff in there to make it burn, you can get the diarrhea and then you can get, how should I put it, a secondary after taste, if you know what I mean. So your bottom hurts.

Troy: It's coming out.

Dr. Pohl: Yeah. So sometimes I'll have teenagers and they get diarrhea and their bottom is hurting, and they're eating like 8 or 10 bags of Takis a day. Just stay away from Takis. So these are things that . . .

Scot: Yeah, sure.

Dr. Pohl: You guys may see this in the emergency room as well, but this is something that I deal with.

Troy: Yeah. Probably, like you said, you see a lot of constipation. I see a lot of people with constipation as well. And it's funny because people say, "Wow, what's the most common thing you see in the ER?" thinking it's trauma or heart attacks. No, it's abdominal pain. And a large number of patients with abdominal pain are just really constipated.

And speaking of constipation, people listening may think, "Well, I'm not having a bowel movement every day, but maybe it's every third day or something." At what point do you get concerned about constipation? At what point does it really become dangerous? If someone comes in and says, "I haven't had a bowel movement in a week," is that concerning?

Dr. Pohl: Well, that is concerning.

Scot: Divide that up into the two different questions that Dr. Madsen asked, actually. What if it's every two or three days? Is that something that somebody should worry about?

Dr. Pohl: My rule, again, is I tell people, "You really should be having a bowel movement once a day." A soft bowel movement once a day. If you're going every three days, I'm going to assume you probably have significant problems with constipation. It's probably general, just primary constipation, nothing else causing it. So at that point, you should consider being on a stool softener.

Now, if you're on a stool softener and nothing is getting better, you should see your physician about that just to make sure there's nothing else going on. In the adult world, you'd worry about things like colon cancers as you get older and things like that.

Troy: Yeah. But it sounds like if you're going, like you said, every third day or so, not great, maybe not an issue or a sign of something worse, but once you get beyond that, if someone is just having bowel movements once a week, then it sounds like that would . . .

Dr. Pohl: That needs to be checked out.

Troy: . . . raise your concern a bit. Yeah, that's a bigger deal. Honestly, I just feel like there's this epidemic of constipation in our country and it's this thing we just don't talk about.

Scot: The untalked about epidemic of constipation.

Troy: I see it so often. Like I said, the most common thing I see is abdominal pain. Quite often, the abdominal pain is caused by just chronic constipation. And people have been to multiple ERs. But it's one of those things if you really get in, "How often are you having bowel movement?" in some cases, they're telling me, "Yeah, it's not often." I've had people tell me, "I haven't had a bowel movement in two weeks."

Mitch: Oh my god.

Troy: That doesn't seem healthy.

Dr. Pohl: Exactly. It's not healthy. Now, I do wonder sometimes when I hear that is . . . Sometimes I wonder if people really haven't had a bowel movement in two weeks, because that would make me feel incredibly sick, or they may be having something and not realizing it.

Troy:Exactly. That's what I wonder too.

Dr. Pohl: But I think you're right. It's a huge part of emergency room settings. It's a huge part of primary care settings.

One thing that we had been worried about for a long time was unnecessary hospital admissions. And it was really interesting, again, basing somewhat on the PDF that we made and the video that we made, we got together with the hospital service and the pediatric ER service about when these kids come in, how to keep them out of the hospital. We found that there were just unnecessary treatments going on where you can just simply give someone a prescription for a safe laxative, talk to them about scheduled toilet sitting times, and when you should be worried about it.

And we looked at it as a quality improvement study and we got it published in a British medical journal. It was actually really interesting. Just doing some simple interventions, we kept these kiddos out of the hospital, which I think correlates very well with adults. Sometimes do we actually really need to admit these patients? There's some stuff we can do at home.

Troy: That's great to hear. Do you ever just recommend straight up essentially what would come down to a bowel cleanse, like a colonoscopy prep essentially, where they're just taking all sorts of MiraLAX in and just clean everything out?

Dr. Pohl: Yes. If they definitely are very constipated, I recommend . . . What we've done with this PDF that we've made is that it has a recipe based on age. And so all of our GI doctors at Primary Children's, we all say the same thing, so you're not hearing different things from different doctors.

If they're very backed up, I'll recommend following that recipe on that worksheet for one day a week for two weeks, or one time, and then start up on a daily regimen such as Lactulose 15 milliliters a day, or MiraLAX one capful a day. I usually write that down for the families.

We try to avoid enemas for a multitude of reasons. One thing that we don't ever recommend are what I call milk and molasses enemas because they are associated with death, both in adults and children.

Scot: Well, that's an unfortunate side effect of the treatment.

Mitch:That's what I was going to say.

Dr. Pohl: Right. So if someone came in simply for constipation and you're doing milk and molasses . . . And people may be asking what that is. Basically, you take some milk and you take some molasses and you kind of warm it up until it gets into a solution, let it cool obviously, put it in an enema bag, and squirt it up into the anus and the rectum.

But the problem is you're doing nothing more than feeding the bacteria that are in there. It produces a large amount of gas, and it can lead to perforation and death. So we are very anti-enema unless we absolutely need to do it. And when we do it, we do normal saline. That's the only enemas we use.

Troy: Do you ever do soap suds enemas or just normal saline?

Dr. Pohl: Nope. Just normal saline. It works very well.

Troy: That's good to know.

Dr. Pohl: Very safe. And you do it like you would do an IV bolus for someone. So in children, 10 or 20 cc's per kilo. I use it like a bolus for a child, and it works very effectively.

Scot: We've talked about how our poop appears could indicate if there's a health issue or when to be concerned or not. What about the smell? Now, you had mentioned that all poop smells. Don't think your poop doesn't stink, as the old saying goes, because it does. Some is just stinkier than others.

For example, when I go into the bathroom at the Health Library sometimes, I smell a smell that is just . . . I'm wondering what's wrong with these people. Is there something wrong with these people, or what's causing it when it gets that smelly?

Dr. Pohl: These are all med students, Scot. You're talking about all these students who have irritable bowel syndrome. I'm going to tell you right now that's . . .

Mitch: They're eating Takis like crazy.

Dr. Pohl: Eating horrible food, free food that they get for showing up for some journal club or lecture, and then combine that with irritable . . . Anyway, that's my thought.

Scot: I mean, the other place that you might smell really bad poop is in the gym bathroom. Sometimes that is just terrible. Are there health concerns if your poop is smelling bad, or is it more a result of just the kinds of things you're eating like Troy is saying?

Dr. Pohl: It's really concerning to me that you have been going to bathrooms and sniffing around, Scot.

Scot: Well, you can't help it. That's how bad it is. It's not like I'm going in there like a dog and . . .

Dr. Pohl: I'm sorry you can't help it. I'm just joking. For example, people who are lactose intolerant or have lactase deficiency because they can't break down the sugar in milk, they will have very foul-smelling stool. Food that has a lot of sulfur in it, like Brussels sprouts, sometimes will do that. And then, again, just the biggest issue that I have seen with people is eating a large amount of carbohydrates in their diet. It's just fermented very quickly. It's just very foul smelling, typically diarrhea.

Scot: Okay. So your junk food and that sort of thing, or anything with lots of sugar in it?

Dr. Pohl: Right. It's like they say: Eat less, exercise more. I mean, if you're eating healthy, this should not be an issue.

Scot: Okay. Protein powders, is that why I'm smelling things in the gym?

Dr. Pohl: Probably. Yeah.

Scot: Do protein powders make it stinky?

Dr. Pohl: Yeah, from the amines. Yeah, probably.

Scot: Okay. All right. And then alcohol too, right?

Dr. Pohl: Right. And there are several issues there. A lot of people probably do have experience with having too much alcohol and then they can get diarrhea afterwards.

Of course, you have to be really careful of that because, first of all, you don't want to drink too much alcohol because of the risk of alcoholism. But if you're doing excessive alcohol, especially in the setting of getting liver disease, the alcohol will basically kill a lot of your good bacteria in your gut and cause the bad bacteria then to overgrow and you can have a release of some of the toxins of those bad bacteria, which will get into the bloodstream and affect your liver.

So there's always the joke about drinking too much alcohol and having diarrhea, but there are a lot of issues in general with drinking too much alcohol. And if this occurs on a chronic basis, you're getting yourself sicker over time.

Oh, and one more thing. Often, and you guys may have seen this, when someone comes in the ER and they say they're having like purple poop or blue poop, ask them what they've eaten. In kids, it's Play-Doh or icing on cake. You can actually buy sparkles. They come in little capsules and you can eat them. And so you can have sparkly poop if you want that too.

Troy:Oh, that's too cool.

Mitch: Oh, no.

Troy:That's pretty cool.

Mitch: Why? Why would we do this?

Scot: Your reaction at first, Mitch, I thought you were excited about it.

Mitch: No.

Troy: I'm fascinated.

Mitch: I'm just so upset with this whole episode, 100th episode.

Scot: This was not the 100th you'd hoped for, huh?

Mitch: No.

Troy: This is not it? This is not the capstone of excellence we wanted to achieve here?

Mitch: No, it's perfect.

Troy: Exactly. That's what I love, though. We're talking about poop. You've already cited a British medical journal article. This is not low-brow stuff. We're talking about high-level research here. So this is good.

Scot: Well, thank you, Dr. Pohl, for giving us the poop on poop. My takeaway anyway is if it's not every day, if it's happening less than every three or four days, that is a problem. It sounds like that, if you have constipation, there are some pretty decent over-the-counter solutions to help you with that, in addition to eating more fiber and drinking more water. And then if it smells, check what you ate first. Is there anything else we need to know?

Dr. Pohl: No, I think that's it. Just to remind listeners that constipation is extremely common. It's one out of every eight Americans. And there are some very safe, non-addictive stool softeners that are over the counter that you can try and always talk to your provider about.

The other thing just to keep in mind is that certain types of difficulty pooping in adults can be associated with colon cancer. And as we get older, you just need to pay attention to that.

And then diarrhea, like I talked about, can be just dietary related or due to a recent infection. But if it's chronic, if you're losing weight, if you're getting up at night with diarrhea, if there's blood in it, you need to talk to your provider right away to make sure nothing else is going on.

Scot: Dr. Pohl, thank you for being on the podcast and thank you for caring about men's health.

Dr. Pohl: I appreciate it.