The Melanie Avalon Biohacking Podcast Episode #157 - Dr. Will Bulsiewcz

TRANSCRIPT

Melanie Avalon: Hi, friends, welcome back to the show. Oh, my goodness, I am so incredibly excited about the conversation that I'm about to have. So, here is the backstory on today's conversation. As you guys know, the audience for this show is often very paleo, and keto, and even carnivore. And I know some of you guys are vegetarian, and vegan, and higher fiber diet. But in general, there's all different perspectives in the audience and the guests that I bring on this show. I get really, really excited when I get to bring on people who are more plant based because I think it can really help open up people's eyes and their perspectives to what diet really does suit to the individual and us as humans. So, back in 2020, a book came out called Fiber Fueled: The Plant-Based Gut Health Program for Losing Weight, Restoring Your Health, and Optimizing Your Microbiome. I remember when it came out, I started seeing it everywhere. I heard an interview with the author, actually on Rich Roll and I was just like, “Oh, my goodness, I've got to try to book this guy for the podcast.” Even my cohost, Gin on The Intermittent Fasting Podcast was obsessed with the book and we would talk about it a lot on that podcast. And so, I tried so hard to book, Dr. Bulsiewicz. We had a connection and I almost booked him but not quite.

And then fast forward, I started working with the company ZOE, which I know a lot of you guys are also major fans of. It's a personalized program that uses a continuous glucose monitor and also gut health tests, and you eat these crazy specially formulated muffins to figure out how you tolerate carbs and fat. In any case, I got to interview the founder, Tim Spector, which was also amazing. And then I realized that Dr. B, who I had been dying to interview was at the time on the scientific board at the company. So, I begged ZOE to introduce me to him. And the connection was made, and here we are, and I just learned that congrats are in order for two reasons. Dr. B, one, your new baby, congratulations and number two, also congratulations that you are now the US Medical Director at ZOE. So, that's very, very exciting. But yes, just welcome to the show. I'm just so excited to dive into everything today.

Dr. Will Bulsiewicz: I'm super excited to be here and I'm a little taken aback. I feel I sound elusive, [laughs] in this introduction. It's funny because I like, “Melanie, just shoot me a message. We'll do a podcast anytime you want. I'll be back in two weeks, if you guys want me to. We can do this.”

Melanie Avalon: Oh, my goodness. I love that. No, I will say it's funny because I was trying so hard. But then when we actually did connect, you've been so personable with the emails and everything and I've just been so, so excited. Oh, and also congrats are in order, because you have a cookbook version of the book coming out pretty soon, right? 

Dr. Will Bulsiewicz: Yeah, actually, it's a cookbook, but it's also not a cookbook. It's an interesting thing. We had to call it something. Cookbook seems like the appropriate word because it's over 100 recipes and it's full color, like, beautiful photography. You feel like you're getting your cookbook for the Fiber Fueled lifestyle. But I'm a medical doctor and doing a cookbook is a very weird thing for me. I felt compelled to use it as an opportunity to try to create a tool for health. And so, I see this cookbook as more of like a toolkit for people who want a healthy gut. It has the recipes that you need, I teach you how to ferment food, I teach you how to bake sourdough, I teach you how to sprout. And for people who have food intolerances which I know there's many of you out there, I teach you how to overcome food intolerances and there's even two recipe-based food protocols. One low FODMAP, one, low histamine, so that I can actually put it into motion for you. It's not just like, “Hey, try this.” It's instead like, “Let me literally hold your hand and give you the recipes that you need to pull this off.”

Melanie Avalon: Oh, my goodness, this is absolutely incredible. Now, I'm thinking we are going to have to have you back right away and [chuckles] focus on the lifestyle plan of all of that. That's absolutely incredible. Well, congrats in advance. So, to start everything off-- I'm stopping myself from diving into some of the things that you already touched on like food sensitivities and histamine. Because I actually, personally follow a low FODMAP diet. So, we're going to have to talk about that one. So, to start things off, for listeners who are not familiar with your work, could you tell them a little bit about your own personal story? What brought you to become so interested in the role of diet and health and in particular, the gut microbiome?

Dr. Will Bulsiewicz: This was not my plan. It's very bizarre for me to be having the life that I do right now, because my dream was always just to be a medical doctor and take care of patients. But at the core, the motivation was, let me try to help people. That's what it always was. I went through 16 years of very rigorous training program like six days a week, 15 to 18 hours a day. Sometimes, 30 hours straight without even eating. In that process, things happened for me that in the moment, I thought I was being cursed, but now looking back 10 years later, I actually believe that I was being blessed. I, because of how crazy things were in my life and how hard I was working, I was at Northwestern in Chicago and I literally got a master's degree in clinical investigation at night. And then I was at the University of North Carolina on a grant from the NIH doing my gastroenterology fellowship.

During this time, I don't have time to barely do my laundry. So, convenience becomes the top priority when it comes to my food. It just needs to be simple, and quick, and convenient, and you know what, I deserved that it tastes good. And so, there was a lot of frankly unhealthy food. When you prioritize convenience, you end up eating a lot of junk food and a lot of fast food. And it tastes great, and it's inexpensive, and then you pay the price. That's what happened to me. I felt like I was in my early 30s about 10 years ago, and I woke up and I'm like, “Look at this man in the mirror. Who is that guy?” It was bizarre because I think of myself as an athlete. I played three sports in high school. But like, “This man has a gut sagging over the belt and there are blood pressure pills sitting on the sink.” My self-esteem is exceedingly low, despite the fact that wonderful things were happening in my professional life that were way beyond my expectations, I didn't feel good about myself. 

I had a lot of anxiety and frankly, I just wanted to curl up in a ball in a dark room under a blanket. That's where I was at. I knew that something needed to change and I'm a very goal-oriented person. I started trying to exercise my way out of it and it didn't work. I could grow stronger or run faster and farther, but I could not lose the gut. And then one day, I was on a date with a person who is now my wife and we have three children together, could have never known that in that moment where this was going to go, we were just on a first date. I look across and she ordered the most bizarre plate of food I've ever seen in my life. I've literally never been around anyone like this. She basically said to the waiter, “Look, I know it's not on the menu, but can you get me some collard greens and some black-eyed peas, in case it's not obvious we're in North Carolina? Can you get me some collard greens, and some black-eyed peas, and some mashed potatoes, and just put it on a plate and make it look nice?” I'm like, “Ah, interesting.” 

But what I noticed is that she cleaned her plate, she ate everything that she had, she was very satisfied, she raved about how good it tasted, she looked absolutely amazing. Her health was completely in alignment. It seemed effortless for her. The meal was done and I was hungover not from alcohol, and she was ready to go into round two of the date, and I'm like, “Yo, I need to go home and put on some sweats. I need to figure out how I'm going to bail it from this day and go rest.” Anyway, this basically motivated me, Melanie to take a look in the mirror at my own diet, and the food that I loved, and the food that frankly was celebrated in my family growing up. I started to make small changes, nothing radical, just quite simply instead of going out for fast food. I need convenience, I'm a single guy, I'm busy, and I'm not a gourmet chef. What can I do? Okay, I can use a blender. I would just take out the blender, throw in a banana, and some greens, and some berries, and maybe some walnuts, hit the buzz, drink that, and instantly, I was energized, and that brought me back to do it again the next night. 

During this process of repeating this habit or this behavior, my skin started to clear up, my hair grew thicker, my self-esteem started to surge, my anxiety seemed to fade, and next thing you know, months are passing and my clothes are fitting me differently. And so, this was a radical transformation for me. It was really empowering, because I'm a doctor. Being on that side of things, it really made me much more empathetic for my patients, but also, it motivated me to want to do better for them. Why wasn't I taught this at Georgetown, and Northwestern, and the University of North Carolina? I didn't understand that. Basically, I started to study nutritional research at night, and then I would bring it into my clinic the next day, and into my work as a gastroenterologist, I was treating people who have irritable bowel syndrome, or ulcerative colitis, or Crohn's disease, acid reflux. And these people are having radical transformations.

To accelerate up to where we are today, this is all happening. I had this very sincere, motivating feeling like, “It is not enough for me to be in this clinic one on one with a couple of hundred people. The world needs to hear this.” And so, I started my Instagram account in 2016, and then in 2018, I had a podcast go viral, and that led me to say, “Gosh, I got to do something even bigger.” So, I decided I wanted to write a book. I wrote Fiber Fueled. My book that came out in 2020, basically, at five in the morning. I was working full-time as a gastroenterologist and taking call every third night. I wrote that book at five in the morning at Starbucks here in Charleston, South Carolina, and it came out 2020. New York Times bestseller, it has now sold 200,000 copies and now, I'm here with my second book, which I'm getting very similar vibes where it's like, I feel I have this exciting, life changing secret that I'm holding that people will finally get to experience on the day that my book launches, which is May 17th.

Melanie Avalon: I love that so much. Just speaking to your book, I normally always have pretty long prep documents, but oh, my goodness, [chuckles] the amount of notes I have from reading your book, it was incredible. The problem and the blessing of this topic is, you reference so many studies, and then I would just get in the rabbit holes of, because once you go look at one study, then it references all these other studies and there's just the scientific information that's being collected on the gut microbiome is just so, so fascinating. I'm really excited to dive deep into all of it. Question about your role as a gastroenterologist, two-part question. One, were you already on that track prior to your diet epiphany or did you switch to a gastro after your change in your diet?

Dr. Will Bulsiewicz: No, I made the decision. When I decided to go to medical school, I started medical school in 2002. I thought I was going to be a pediatrician and then it was probably fall of 2004 was when I discovered gastroenterology. I fell in love with the digestive system, which sounds very weird. 

Melanie Avalon: Oh, not at all. [laughs] It doesn't sound weird to me. [laughs] 

Dr. Will Bulsiewicz: If you follow me online, you know I love poop jokes. You can see where this was coming from. [laughs] Yeah, so, I fell in love with it and I made the decision then in 2004 that this is what I wanted to do. This transformation that I'm describing to you really is taking place 2013 into 2014. That's when that was all happening. It was 10 years later that all these things started to fall into place for me. 

Melanie Avalon: My second question knowing all of that is, conventional gastroenterology, your perception and your paradigm with the role of the gut microbiome on our diet and its influence on everything? Because I imagine, you talk to your patients a lot about the role of diet and all of that. But how does it actually affect conventional gastroenterology practices that you do? So, colonoscopies and procedures and things like that, do you still engage in all of the conventional stuff? Is there even that difference between conventional and a holistic approach? I'm just wondering how it really informs your practice.

Dr. Will Bulsiewicz: Well, I see the [unintelligible 00:13:27] that exist, but I personally don't feel boundaries, in terms of the way that I practice medicine. I feel at the end of the day, my job and my motivating factor is that my patients deserve the best. And so, it is my responsibility to ensure that I'm adequately informed to provide that to them. And really, the game changing moment was the fact that my life was changed by changing my diet. From that point forward, there was no denying that in my mind this needs to be a part of what I do in the care of my patients. I started to grow my understanding of the topic, not just diet, but also the diet and the microbiome interaction, because I'm a gastroenterologist. So, it makes too much sense. 

But the problem is that, Melanie, people are not trained in nutrition in allopathic medicine. My training in nutrition have been giving some of these timeframes to people. I did two weeks of nutrition in 2003. That's what I was taught. For me, this was motivated by an intrinsic desire to try to understand and try to help my patients. But the problem is you have to understand the healthcare system does not support this. And I'm not saying that in a conspiracy way, where the healthcare system is trying to stop this. I'm saying, the healthcare system does not support this because they don't teach doctors, they don't allow doctors the time, and they don't pay doctors for this. You really can't expect this to happen. If you're not going to teach them, or give them the time, or pay them to talk about nutrition. It's just not going to happen.

Melanie Avalon: Gotcha. And then I imagine speaking to that because there is the whole branch of doctors that exist outside of the insurance system and take on more holistic approach. But when it comes to actual, I don't know, I'm speaking out of my wheelhouse here. But it seems when it comes to actual medical procedures and stuff that that has to be through the system or does it? 

Dr. Will Bulsiewicz: Well, in order to do colonoscopy, you have to have a medical license and you have to have the proper credentialing to do that. For example, I'm allowed to do that because I did training where I did thousands of colonoscopies prior to the day that I was cut free to do that independently. So, can a person focus on digestive health and not provide colonoscopies? Of course. Is healthcare more than allopathic medicine? 100%. I am of the belief that-- People ask me all the time, “How do I find a provider that is going to give me what I need? How do I find someone like you, Dr. B.” That's nice. I appreciate that. But actually, the answer to the question is, you don't find one. You build a team.

Melanie Avalon: I love that. And then on the flipside, the irony of the further confusion is, there is a slew of people like my audience who do dive deep into the research and we do really understand the importance of diet and how it affects our health and the importance of the gut microbiome. But then, there's all of these perspectives about the right diet to follow and like I mentioned earlier, keto and carnivore versus plant-based and vegetarian and veganism. So, here's where I'm really excited to dive deep into everything. Maybe a foundational question that we can start with because we could start with diet or we could start with the microbiome. But one of the things I loved in your book is, when you answer the question, what is the microbiome, I think a lot of people think microbiome and they think bacteria, and then they're like, “You're done.” But you talk about there's actually five parts to our microbiome. So, I was wondering if you could just briefly educate us on, what is the microbiome? 

Dr. Will Bulsiewicz: Cool. Yeah, definitely. The microbiome, this is the new frontier of the 21st century and I don't just mean in terms of science, in general. There're certain things that are major breakthroughs for humanity during each person's lifetime and this is what's happening right now that is revolutionizing the way that we think about human biology. That's because we've discovered and this discovery is very recent, literally, in the last 15, 16, 17 years. We have discovered and started to really understand this community of microorganisms that's a part of who we are. We as humans are not functioning in isolation. I’ve realized that's weird to say, but we are a super organism that actually is reliant on smaller, invisible microorganisms in order to be the best version of ourselves. We actually need them. Covering us from the top of our heads to the tip of our toes are invisible microbes. And you can't see them, but if you had a microscope and you took a look, you would see that your body is teeming with life everywhere. On your skin, in your mouth, in your nose. The area where it's most concentrated is in your colon, which is the large intestine. In that place, you will find 38 trillion microbes, which is a pretty overwhelming number. 

Trying to put this into perspective, what is 38 trillion? Okay. If we take all of the stars in our galaxy, that's about hundred billion stars. We would have to condense them down and place 380 galaxies full of stars into your colon [chuckles] to equal the number of microbes that are living inside of all of us. All of us. Not just me, all of us. And so, they are there with a purpose. They're not just hanging out. They have been a part of human evolution since day one. I don't believe there's been a second in the history of humanity that has not included and involved our little microbial friends. We coevolved together, we rose and we fell together, and through galvanizing that relationship over millions of years, we really, really grew to trust them. I'm just saying from a doctor's perspective, if you look at the way that we work as humans, wow, we are really trusting these microbes, because we need them for digestion and that is access to nutrients. That's life. We can't live without that. We need them for our metabolism, for our immune system, for our hormones, for our mood, for brain health. 

Basically, everything that matters for human health in some way is interconnected. This is not the only thing that matters, but this is a big part of what matters for all of these elements of human health. And the crazy part about it is like, “Yo, they're not even human. They're not even a part of our body, but we need them so desperately and we need to nurture this relationship.” That's a big part of my message is. Let’s not ignore our microbiome. The science is exploding, it's emerging, it's exciting, and what it's telling us is let’s stop ignoring them, and neglecting them, and let's start weaning into them and nurturing this relationship just like you would nurture a relationship with someone else that you love. 

Melanie Avalon: I feel there was this idea that they outnumbered our own cells a certain ratio, but then we realized more recently that it's not that high of a number?

Dr. Will Bulsiewicz: Okay. Yeah, thank you. This is actually unpacking this. The old idea was that we are 90% microbial and 10% human. That was the old idea. There was a revision and the revision, which I think came around 2015 or 2016 said that we are less than 50% human for sure that we have 38 trillion microbes and we have about 30 trillion human cells. But the issue though is, if you look at the 30 trillion human cells, the vast, vast, vast majority of them are things like platelets and red blood cells, which are not like the classic cells that we would usually think of. To me, a cell means a nucleus, and endoplasmic reticulum, and mitochondria, and all that. If you looked at just those cells, the eukaryotic cells, the classic cells, we actually are 90% microbial and 10% human.

Melanie Avalon: I was going to ask you about it, and I was like, “Oh, I should have looked this up to have the right stat," but I'm glad you're very familiar [chuckles] with what happened there. Okay. And then to the actual breakdown of these organisms, so, maybe we can go through what they are and then I have a huge question. I'll go and just ask it which is, are any of them good and/or bad? Does that even mean anything? Are they neutral? What is the breakdown, and are they good or bad, and can we maybe even define what good or bad would even mean?

Dr. Will Bulsiewicz: Yeah, let's describe what we understand about these microbes. It's important to understand that where we were 15 years ago was, “Oh, look at this one microbe. Look at what this one microbe does.” We are way more complicated than that. We are hundreds of species of different microbes and they are working as teams. There're basically groups of them that are collectively working on tasks in unison together. First one does this, then a different one does that, then a third one does this. It's amazing. We are made up of five main types of microbes. You mentioned this earlier, Melanie. So, just to unpack this. The main one are the bacteria and it's time for us to revise our understanding of bacteria. We have been vilifying bacteria for 100 years. Yes, there are some bacteria that are bad. The vast majority of them are really good. The number two thing are the fungi or the yeasts. This includes Candida, but this includes many other different types of yeasts. They're far less represented than the bacteria. The third are the archaea. These are my personal favorite. 

Melanie Avalon: I'm obsessed. 

Dr. Will Bulsiewicz: Yeah. They're not bacteria and they're not yeasts, but they are the most primitive microorganisms or frankly, life on the entire planet. We literally believe that this is the first life on the planet, were the archaea. There was a place in Greenland where they did an archeological dig, and they carbon dated the archaea to four billion years ago, which is fascinating. Because oxygen has only existed for 2.5 billion years and humans have only been around for three million years, which is almost nothing. These archaea, they are hearty, they are resilient, and I'm pretty sure no matter what happens with global warming or this planet, they're going to be fine. They live in the bottom of the ocean in a rift vent, they live inside of volcanoes, and then their third option is to live inside your colon. You can decide which of those three you would personally choose as your home. I would probably go inside someone's colon. Yeah, so, the archaea are the third type. 

We may have parasites. Parasites is a derogatory word. But much like bacteria, we need to be careful there. There's actually some that are really good. Some of our research with ZOE has found that there's one called blastocystis that actually is really good for your metabolism. It helps you. And then finally, the fifth are the viruses. Viruses, again, another loaded word these days for obvious reasons. But viruses, actually a normal part of the balance that exists within our microbiome and we actually believe that we have more viruses than we even have microbes, which is crazy.

Melanie Avalon: Okay, so, the reason I personally was obsessed with archaea was, I got diagnosed in the past with small intestinal bacterial overgrowth, SIBO, IBS-C with constipation. I did a lot of research and it would come up that archaea were responsible for methane production and I needed to combat the archaea in order to solve my IBS issues. So, it was definitely really interesting. reading your book and hearing a pretty different perspective on all of that. I’ve so many questions about this. 

Dr. Will Bulsiewicz: Can I talk about that?

Melanie Avalon: Yes, please do.

Dr. Will Bulsiewicz: Okay. Yeah, just real quick. Because I do want to comment on that. It's common conventional education to say that the archaea must be bad because they produce gas. Any person who's constipated, I'm just going to tell you the number one symptom of constipation is bloating and gas without a doubt. There's something that I would describe as a vicious cycle that people need to understand when it comes to constipation. First of all, constipation is epidemic. I'm quite positive that some of your listeners right now are going to be perking up because there I call, “Gosh, this is me or this is someone I know.” There's a vicious cycle in constipation. Methane gas actually produces constipation. When you have more gas, you actually slow bowel motility. But when you are constipated, you produce more methane gas. And so, it creates this vicious cycle where gas produces constipation produces gas and round and round we go into, “Hey, I'm never pooping.” 

Now, the archaea may be producing the gas. But I would encourage us to think differently than the traditional approach, which is always if it does something that we don't like, we have to kill it. That's what we've always done. But that doesn't always work out very well for us. Sometimes, we're better off nurturing the good guys or looking at other avenues to overcome what we see as a problem as opposed to just trying to destroy it. The reason why is because archaea are actually known to protect us from heart disease, which is our number one killer. We don't necessarily want to kill archaea nor have I seen clear cut evidence that by killing archaea, we can actually fix constipation. I haven't seen that evidence. If you were in my clinic, the way that I approach this is to first focus on getting you pooping. If I can get you pooping and get you into a rhythm, once we get that rhythm going, when you are pooping, the gas and bloating goes away, period. And then we don't have to worry about killing the archaea. They can continue to protect us from heart disease.

Melanie Avalon: Two big questions right there. I'm just loving this conversation. One, getting the patient's pooping like you say. Does it need to be a completely natural peristalsis like you wake up and you use the restroom or can it be somebody taking a lot of magnesium and keeping things flowing through a route like that? 

Dr. Will Bulsiewicz: Well, so, there's multiple different approaches to how to treat constipation. It's a bit of a nuanced topic. Actually, I have a course that I offer on my website where I will literally teach for two hours on this topic. 

Melanie Avalon: Oh, [laughs] yay. 

Dr. Will Bulsiewicz: Yeah. But the answer is this that the key from my perspective is to get people into a rhythm and get them pooping. To use magnesium to accomplish that is not something we should feel bad about in any way at all. Because the reality is that if you look, I don't care what diet you eat. There are a bazillion of us that are deficient in magnesium right now. People who have very healthy diets many times are still deficient in magnesium. And so, if you take a magnesium supplement, the magnesium supplement can help to facilitate good regularity of your bowel movements. It does not work through stimulating the colon, which is an important point, because stimulating the colon, the problem when you stimulate the colon is that when you take away the stimulation, the colon becomes sluggish and your constipation gets worse. That's what we see with things like Senna, or Smooth Move tea, or aloe. Don't hate me people. Sorry, but aloe or there's something that's used in the Latin world, cascara.

Melanie Avalon: Yeah. I was going to say cascara. Yeah.

Dr. Will Bulsiewicz:  These are stimulant laxatives. The problem is that they make you poop, they work. Many people who are constipated, they're like, “I need this. This is the only way I can go.” But the problem is then they become dependent on it, where they try to withdraw it and it's problematic. The good thing about magnesium is, it doesn't do that. There are a couple of quick tips. There are many forms of magnesium. Not all of them work for pooping. The ones that I like are magnesium oxide, magnesium citrate or magnesium sulfate. You work with your healthcare provider, you check your magnesium upfront just to make sure that it's where you want it to be and that it's not high. It's extremely unlikely to be high. Then you start taking about 500 milligrams before bedtime. You give it at least a couple of days to see how that's working for you and then if you need to you can crank it up by 250 milligrams at a time up to 1,000 or 1,250. 

The point being once you get on a good stable dose, you then repeat your magnesium level with your healthcare provider just to verify that it's where you want it to be. Most of the time, what I find is people start low and they end up right where you want them to be by the time they get on the right dose.

Melanie Avalon: Okay, I am loving hearing this. I'm actually because I just recently launched a supplement line and my next supplement is magnesium, because I just think it's so, so important. It's a game changer for me personally for bowel regularity. What so just—Oh, get on my soapbox a little bit. I recently had a colonoscopy, because I tend to get anemic. And so, it was for that. The gastro was asking me, “What do I do to manage my bowel movements and constipation?”. I told her that I use magnesium that it works really well. She was insistent that I needed to switch to, what is that? propylene glycol? 

Dr. Will Bulsiewicz: MiraLAX. Yeah, that's MiraLAX. 

Melanie Avalon: And I was like, “But the magnesium is working” and she's like, “No, there aren't studies on that. You should switch to the MiraLAX.” I was like, “Why? That doesn't make any sense to me.”

Dr. Will Bulsiewicz: Yeah. Well, that's not true. There are studies. There are studies that have clearly demonstrated that magnesium can help people to have good regular bowel movements. This is not a silver bullet. There are some people that it's not going to work for. There are some people that potentially need medication. One of the things that I should introduce, Melanie, I hope you don't mind, but I think this could be a game changer for some people who do have constipation is that people need to understand that not all constipation needs to be treated with medication, all right? There are different forms of constipation. Sometimes, it's slow transit. Meaning that your colon is not moving as efficiently as it should. Magnesium is great for that. Other medications, good for that. But many times, particularly in women, constipation can be related to the pelvic floor. And basically, what this is, we call it pelvic dyssynergia. Dyssynergia meaning, loss of synchrony. We take for granted that when we sit down on the toilet, we're going to have a good, complete, relaxed evacuation. That's not the experience for everyone. 

Many people strain to try to get it out. Many people push super hard to get a little nugget to slide out. And also, many people feel like they haven't had a satisfying bowel movement. They go, but they didn't really go. They didn't really empty. It's just like, “I feel I still have to go.” Or, maybe they go again in 30 minutes. All of these people, it's possible that it's a pelvic floor issue. The treatment for the pelvic floor-- By the way, everything that we're talking about, I cover constipation actually quite heavily in my new book, the Fiber Fueled Cookbook much more than I did in my first book Fiber Fueled, because the Fiber Fueled Cookbook is much more solutions oriented than Fiber Fueled was. In the book, I describe what I would say are the big three of food sensitivity, one of them is constipation. 

Anyway, the approach to pelvic dyssynergia is, number one, you want to get tested to demonstrate that you have it. It's a test called anorectal manometry. Once you do that test, if you have this, the treatment is not medication. It is physical therapy. Because it's the muscles that are out of alignment. And much like if my shoulder is not working properly, the treatment for my shoulder is not ibuprofen. That doesn't make my shoulder work properly. That just covers up the pain. The treatment for my shoulder is physical therapy. I work to get the muscles back in alignment and work in the way I want. The same is true for a pelvic floor sometimes.

Melanie Avalon: That is a game changer. I had not come across that in my mini-rabbit hole tangent moments research in constipation.

Dr. Will Bulsiewicz: Well, here's the reason why I think people need to hear about this because this is completely real. It was not acknowledged or recognized up until probably about 10 or 14 years ago. It's fairly new. Meaning that there are some doctors that this wasn't part of their training. The people who have this in my experience are the people who have been banging their head against the wall with medication and not getting better and they're frustrated, because they're like, “I'm taking ridiculous doses of Linzess. Linzess is one of the powerful medications people take. They're like, “I'm taking the highest dose of Linzess, plus MiraLAX, plus magnesium and I still can't poop.” Okay, that's not a medication issue. That's probably a pelvic floor issue. Because medications don't work to fix the muscles of the pelvic floor. That's why you're failing. When people are struggling with constipation and medications are quite simply not working, I'm telling you right now, write this down, talk to your doctor. “Is it my pelvic floor?” That's what you need to do.

Melanie Avalon: When I did get the colonoscopy, she said, I had a twisty colon. Could that be involved in constipation? Is that common? 

Dr. Will Bulsiewicz: It's an interesting question. It's an interesting question, because we don't really know. We all have twisty colons. [chuckles] I can tell you for a fact having done like I don't know how many thousand, probably more than 10,000 colonoscopies. I can tell you that there are some people that is more difficult to perform their colonoscopy than others. In that setting, it's a chicken or egg thing. You know that they're constipated, you know that their colonoscopy is difficult, and the question is like, “Is the difficulty of the colonoscopy related to the constipation or not?” You know what I mean? I guess, it's not so much a chicken or egg thing. It's more like, “We know this is true, we know this is true, but are they related?” That's the question.

Melanie Avalon: Then another thing that I was thinking about you touch on the book and this actually ties into the psychological aspect of things. But I remember when I first came across the term visceral hypersensitivity, is that the term, about basically people with IBS being more sensitive to gas and bloating? I remember the first time I read that it actually made me upset, because I was like, “What? They're saying, I'm just more sensitive and it's not actually as bad as I think it is.” But then on the flipside, I've had a concern around not wanting to be constipated. I remember, one time, I didn't feel constipated. I felt really good. And then I went and got an x-ray and the x-ray said I was constipated. And so, then that did a psychological number on me, because then I was like, “Oh, so, even if I don't feel anything, I probably am still constipated.” So, I guess the question from all of this is, what is the role of our perception of how we feel when it comes to these IBS issues and constipation and stuff?

Dr. Will Bulsiewicz: Well, so, these can be complicated issues. Let me start by saying this. Treat the person. Don't treat the laboratory values or the x-ray. A person who's constipated, almost always has gas and bloating. If Melanie, hypothetically, you are my patient, and I treat you to the point that you feel like you are having good, complete, regular evacuations, not just good, great and very satisfying. Dare I say that. In addition, this gas and bloating, which has been a chronic problem for you for years to the point that what archaea are that this goes away. It's gone. We won. The war is over. We won, right? I don't care what the X-ray says. Now, flipside, you are pooping way better than before. But you still feel there's some incomplete bowel movements. Not fully satisfying. There's still a little bit of struggle there and you're still having a little bit of bloating. The question is like, “Are you constipated?” Well, in that case, the x-ray is helpful because if the x-ray does show a lot of constipation, then it helps us to understand we don't need to go searching for other explanations for your bloating. We can focus on just making you poop a little bit better and that should take us where we want to go.

Melanie Avalon: Okay. I'm glad you brought that up about treating the person not necessarily the x-ray or things like that. A big question I have about that is, you talk a lot in the book about low FODMAP diets, and gluten-free diets, and people who go on to these diets, and the potential issues with long-term elimination diets, and how it might affect the gut microbiome, and whether or not there may be nutritional deficiencies. So, what is the role of treating the person versus treating the thought of how it's affecting the gut microbiome? And so, to further elaborate on that, for example, say, a person goes on a low FODMAP diet and I guess, we can define what FODMAPs are, that goes on a low FODMAP diet and experiences remission of symptoms, but we see in studies that might have a negative effect on “beneficial bacteria.” I guess, I wonder how much of an issue is that and to further elaborate. So, I thought this was so interesting, because I was reading some of the studies that you referenced about the long-term effects of gluten free and also low FODMAP diets. 

I found it so interesting because two completely different studies. We’re looking at low FODMAP diets and how they affected the gut microbiome. Both of them use the word paradox, which I thought was so interesting because it insinuates that we have an ideological perspective that we're bringing to looking at the data when we see this paradox. And so, the paradox is were in one of the studies, the people on the low FODMAP diet saw a decrease in Bifidobacterium, which are “good bacteria,” but their symptoms improved. And then the other study, symptoms improved, they had lower abundance of actual bacteria, but they had the stable-- We can talk about this, too. Stable short chain fatty acids. And the paradox was if the bacteria are down, but there's no seeming effect on the short chain fatty acids. I guess, stepping back that was a lot of information. If people go on a certain diet that's making them feel better, but were concerned that it might be negatively reducing “beneficial bacteria,” how much of a problem is that? That was a long question. 

Dr. Will Bulsiewicz: Yeah. No, no, I think that in order to proper-- because this is very nuanced, and there's complexity to this. I don't like painting with broad strokes to the point that it's overly simplistic. But at the same time, I want people to have a feel for how this works. I think analogies can be very helpful in this type of situation rather than focusing on the gut microbiome, which is so complicated. Let's step away from that for a moment and let's use an analogy. Let's talk about like what if you hurt your knee? You're talking about the low FODMAP diet and you're talking about symptoms improving like you don't have discomfort because you go low FODMAP. But then what does that mean for your gut microbiome. In my knee analogy, let's pretend you hurt your knee. Your knee is like your gut microbiome. The discomfort that you were talking about with the low FODMAP diet, that's the discomfort that you feel when you try to walk. 

When you hurt your knee, you have the option if you want to to stop walking for the rest of your life. If you do that, then you will not feel pain in your knee. Okay, there's some value to that. But the problem is that your knee is not going to heal. In fact, it will probably get worse, and then the muscles above and below the knee get weaker, and you are more sedentary, and you suffer metabolic consequences, and this all snowballs slowly into something that's more dangerous. No one does that because every single one of us knows that if your knee is damaged, well, we got to restore the knee. We have to get our function back. I want to be able to play basketball again. But I can't play basketball right now. I need a physical therapist. I need to work through a training program. And that training program, basically, what I'm going to do is over the course of not one session, but multiple sessions. This is going to take some time. I'm going to work with this professional and each time I go, they're going to challenge my knee. 

Because the challenges are tailored to where I'm at, when I'm really beat up, we're not going to do a serious challenge. We're going to do a mild challenge. But as I grow stronger, the challenges will become progressively more intense. Because we custom tailor it, we're minimizing the amount of pain. We're not just running towards the pain, we're not putting us through something that we don't need to put ourselves through. But what we are doing is we're acknowledging. Yes, there may be some discomfort in this process of rehabilitating our knee. But through a series of progressive slow challenges and then allowing your knee to adapt and grow stronger to what you just did, you can eventually challenge, challenge, challenge until now your knee is back to full strength. And now that you're back to full strength, there is no pain and you have restored functionality to your knee. You don't have those limitations. 

Coming back to the microbiome. When a person struggles with FODMAPs, FODMAPs are the fermentable parts of our food. It's not because they have a food allergy. It's not because they are inflammatory there is zero evidence of that. It's because they're struggling to process and unpack that food. The reason why they're struggling with the FODMAP is because they have a damaged gut. If we withdraw from the FODMAPs, the problem is that FODMAPs are actually prebiotic. They're actually good for our gut microbiome. Withdrawing permanently from those FODMAPs will make our gut weaker. That's what we see in the studies that you're describing. But the problem is, how do we then overcome this? Well, the solution is we heal the gut. Because when you heal the gut and you go through a series of steps much like retraining the knee, starting low and going slow in challenging your gut, your gut will rise to those challenges much like your knee did. Over the course of time with those challenges that get progressively bigger and bigger, you are allowed to retrain your gut, so that you are restoring functionality, so that your gut becomes capable of processing and digesting those foods that you thought were your enemy and you've now turned them into your friend. 

It's a nuanced topic. It's not that easy, it's not like, “Oh, just get rid of it” and it's also not like, “Oh, just eat it.” Instead, what it is, is we need to work through a process where you rehabilitate your gut because the gut is the problem, not the food. But if we really truly want to get you back to where you need to be, then that means getting you to a place where your gut is healed and now you can consume that food without restriction. And that's possible. That's what my new book is about.

Melanie Avalon: Some questions about that. So, when we say damaged gut, how would we define that? Is it dysbiosis of microbiome, is it the intestinal wall? What is damaged exactly?

Dr. Will Bulsiewicz: Well, I think the term dysbiosis is appropriate. The role of these gut microbes is to help us to process and unpack our food. That's what they're there for. The issue is that when they are impaired, if they don't have the proper microbes available, if they don't have the functional capacity that we need, they can be overwhelmed. The foods that you need them the most, for example, legumes or whole grains, these are very high fiber foods, we need our microbes more to unpack fiber. And so, when we go hard on legumes or whole grains, we feel that discomfort, again that is not inflammation, there's no evidence of that. That is sloppy digestion and it's evidenced that your gut microbiome is struggling with that food. Underlying if we were to look under the hood, that's a damaged gut, that's dysbiosis or as people may refer to it as leaky gut, that's dysbiosis. How do I know that a person has dysbiosis? Not a stool test. At least, for me, that's not what I do. What I do is I ask them like, “How do you feel?” If they tell me that they have a chronic issue with a specific food, a food intolerance, the presence of a food intolerance by itself is indicative of a damaged gut. That's the reason why you're struggling with that food.

Melanie Avalon: I'm glad you said that because I was actually going to ask you about that concept, that a food intolerance is indicative of a damaged gut. I don't know if we should use the word 'perfect', but perfect person in theory would be able to digest anything because they have the strains ready and waiting to digest anything or they'll always be some transition period to adapting and learning to digest something new?

Dr. Will Bulsiewicz: First of all, I apologize for this, Melanie. It's not your fault. But I get a bit triggered by the word perfect. [laughs] 

Melanie Avalon: You didn't see me, but I was doing air quotes with my fingers. I was like, “Perfect.” Yeah.

Dr. Will Bulsiewicz: Because I'm so reluctant to use this word. I understand that you were being very cautious with it, too. I'm very reluctant to use this word, because perfect I feel is a figment of the human imagination that doesn't actually exist. Instagram and social media would present itself as if perfect exists and it does not. So, we're all just doing our best. Our gut is imperfect. Our gut for every single one of us, no matter who you are has strengths and it has weaknesses. If we were all bodybuilders, we would have strengths and we would have weaknesses. But if we wanted to do a different sport, I don't know, a professional bodybuilder, and then make them into someone who does yoga. Their body is not adapted to that. Professional bodybuilders are not yoga people. [laughs] They're not designed for that. 

Our gut microbiome is designed and adapted to whatever we have been eating for the last three months. Anytime that we change what we're eating, we are challenging it. We are asking it to adapt and evolve to whatever it is that we want to do. If you have not been consuming legumes, I'm going to tell you right now, the hardest part about reintroducing legumes is accepting that it's going to be difficult in the beginning. And that's because you just don't have the bacteria right now in the right form to help you to unpack these foods. But if you start super low, literally, two black beans and you start there and then you go to four black beans, and then the six black beans, and you start moving up, you can build them back up. So, these weaknesses that exist within our gut, they're adaptable. They can be taught and they can grow stronger much like we have different muscle groups in our body. If I want to make my chest stronger, I do the bench press. But if I want my biceps to be stronger, I do curls. If you want to be better at consuming beans, consume some beans. If you want to be better consuming whole grains, consume some whole grains. If you don't want to be stronger with those things stop consuming them. You will grow weaker. That's like saying, “I'm not going to do my biceps anymore.”

Melanie Avalon: I'm trying to exist within this analogy. So, you'll grow weaker with that specific muscle or systemically like your whole body, your overall health implications?

Dr. Will Bulsiewicz: Obviously, all muscle groups are intertwined. Our body is intertwined. But no, I really am more focusing on that one muscle group. If you stop working out your biceps, but you're still working out your triceps, it's going to be some weird-looking arms. Because the biceps don't grow stronger when you stop using them. They grow weaker. If we stop walking, our legs grow weaker. But if we start training our legs, they grow stronger. I think the point is that our body is constantly adapting and evolving based upon our diet and lifestyle. Whatever you take in from your environment, your body rises to the challenge. If you want to become a marathon runner, you are capable of doing that. But you're not going to start today and run 26 miles. You're going to train your body until you get to the point that you can do that. If you want to be a bodybuilder, you will go to the gym and you will lift heavy weight. If you want a healthy gut, then what you will do is, you will go through the process of recognizing and understanding where the weaknesses in your gut exist, because it's not just categorically weak. 

All of us, you have strengths and you have weaknesses. If we understand our weaknesses like what are the foods that we struggle with, then you are an empowered person. Because now, you can turn your attention to those specific foods and say, “Here's where I need to do some work. I need to focus more on legumes, or I need to focus more on whole grains, or I need to focus more on fruit, or whatever it may be” and you can build your gut up, so that it's capable of becoming strong again.

Melanie Avalon: A question about that as well, you gave a really fascinating statistic in the book about basically, the amount of enzymes we naturally have to digest carbs and fibers like 17 or something. Somewhere around that number compared to the potential digestive enzymes of gut bacteria, which was a huge number. So, where do those bacteria exist? What I mean by that is, so, say that a person has trouble digesting legumes. Do they bring in when they eat the legume? Are they introducing that bacteria that provides the ability to digest it or is the bacteria already residing in them waiting to be reawakened and built up? Because if it's the latter, isn't it possible that some people they just don't have that bacteria?

Dr. Will Bulsiewicz: We all have a unique microbiome with specific unique strains of microbes. But the good news is that it's never just one bacteria. There're always these redundancies that exist within the microbiome. Certain bacteria can be replaced with different bacteria that is capable of doing something very similar. And so, we're not overly reliant on, “Oh, well, if you're missing this one bacteria, then you are simply incapable of doing this or incapable of doing that.” To answer your question. I think there's an interesting study that was of the Hadza, which are a tribe of people that exists in Tanzania in Africa. And I'm sure your listeners have heard about the Hadza. They're into paleo and keto and they continue to live a hunter and gatherer lifestyle. They are non-agrarian and they have studied the Hadza, the microbiome of the Hadza and what's fascinating is that there are microbes that disappear when a berry is out of season. And then when the berry comes back in season, the microbes reappear.

Now, basically, what that says to me is that, again, the microbiome is adapting to the needs of this person. When they're ready to eat berries, the microbiome is there to help them eat berries. But when they're not eating berries, then you don't need those microbes and therefore those microbes will recede. My suspicion, I don't know for sure because it's hard, Melanie, because there're limitations to our testing. Our testing can detect it down to a certain level, but what if the microbes are below that level? My suspicion in this Hadza example that I'm giving is that the microbes are below that detectable limit, but they're still present. You call them dormant if you want to. They're there. They're just not really active in a way where they could really do much to help you. But once you bring the berries back on to the menu, all of a sudden, boom, here they come back to life. And so, I think that it's likely that we have microbes that we're capable of activating by reintroducing foods that we haven't been consuming.

Melanie Avalon: I was literally just going to ask you about the Hadza, so and so. I was going to ask you about the seasonal eating of them. Are the Hadza, do they consume grains? Are they gluten free?

Dr. Will Bulsiewicz: Gosh, that is a great question. I don't know with complete clarity, but I don't think they bake bread. They eat a lot of tubers. They are very high fiber. They consume, we believe potentially a hundred grams of fiber per day, because they're eating a lot of roots and tubers. I would not expect that they would have gluten in their diet because they don't eat wheat. They're not growing wheat, rye, barley. That's not a part of their diet.

Melanie Avalon: Yeah, I was just really curious, because we know you use them as an example of, I guess, ancestral gut microbiome that hasn't been tampered and messed with by the modern diet, which is full of so many issues. But it ties into, because you talk a lot about gluten in the book and that was a bit of a paradigm shift for me. And you talk about celiac disease. What are your thoughts on a gluten-free diet and who shouldn't go on one? And are there potential issues to long-term gluten restriction?

Dr. Will Bulsiewicz: Okay. So, I love it.

Melanie Avalon: The question? 

Dr. Will Bulsiewicz: Yeah. No, we are touching on the good ones here. Let me unpack gluten a little bit. First of all, gluten is a protein. It's a protein that is found in wheat, barley, and rye. If you have celiac disease and you consume gluten it activates your immune system in inflammatory way, that is problematic. In people with celiac disease, gluten is off the table. All of these things that I'm talking about like low and slow, reintroduce, it's about variety and abundance, that does not apply to a person who has celiac disease. If you were in my clinic and you have celiac, I would say, “You need to be gluten free and you need to be gluten free for the rest of your life. There's no bringing it back.” But let's move beyond celiac disease. By the way, I mentioned earlier that there's a big three of food sensitivity and I said that constipation was one of the three. The second is celiac disease. So, we're touching on it right now and the third is gallbladder dysfunction, which is another thing that can cause food intolerances. If you fix any of these three, people's food intolerances get way better. 

Now, with celiac disease it becomes imperative that you rule this out. I want people to understand that a blood test is not adequate. The vast majority of people that I have diagnosed with celiac disease, they have a normal blood test. I was raised being taught, by raised I mean in a healthcare system, being taught by the healthcare system in my medical education that these blood tests were really reliable for celiac and it is not true. We misunderstood what is celiac disease. The reliable test for celiac is an upper endoscopy. You have to go down into their small intestine and take biopsies and people have to be consuming gluten in order to do that properly.

But let's assume that that a person does not have celiac disease, okay? We're moving beyond that. They have heard that gluten is inflammatory and gluten is implicitly bad for the gut microbiome. The problem is that if you look at research studies, not in a test tube, which is I think a quite unnatural way to measure what I do and how I live. So, rather than looking at a test tube or a rat study, let's look at real humans eating a slice of bread. What happens? What we see is that when people eat high-quality sources of, for example, bread or high-quality carbohydrates that do include gluten, their microbiome becomes more healthy. Their inflammatory markers actually go down. The reason why is because wheat actually contains a lot of prebiotic compounds that are good for our microbes. Flipside, we all know that wheat includes a very broad spectrum where it could be high-quality sourdough bread, but it could also be total junk food. The vast majority of wheat-based calories in your supermarket are junk. I am not advocating for those in any way. Those are not healthy foods, but that's not exclusively because of gluten. They just happen to contain gluten and be unhealthy foods. 

They did this study, Melanie, that I think you may have been leading me into a little bit. So, I'm going to talk about it, where they looked at people who have what's called a gluten intolerance. What this means is that when they consume gluten, they feel unwell. Like they have gas, or bloating, or cramping, or abdominal pain, or something like that. First of all, they verified that these people, they do not have celiac disease. Celiac disease is off the table. As I said, if you have celiac, you need to be gluten free. In this group that does not have celiac disease, they sent them home with three weeks’ worth of breakfast bars and they said mark down every single morning after breakfast, how you feel, how many symptoms you're having? The three bars were first, the placebo, that's our baseline. We're going to compare to that. Number two, a gluten-containing bar and number three, a bar that contains what are called fructans. Fructans are FODMAPs. When they analyze the results, it was a bit of a surprise. 

When people consumed the gluten-containing bar compared to the placebo they actually had less symptoms when they were consuming gluten than they did when they consumed the placebo-containing bar. Placebo bar was more of a problem than gluten. When people consumed the fructan-containing bar, they were triggered. The fructans, which coexist in wheat-containing products are the reason that people get gas, bloating, discomfort when they eat wheat-containing foods and that's because they are FODMAPs. But they're also prebiotic. They should not be thrown out, we should not be vilifying them, we should be looking at ways to overcome these limitations and restore function to our gut, make it stronger, so that we can consume these foods. That's what you and I have been talking about for most of our conversation today. 

The point is this. Here's how I see this. If you are celiac, you need to be gluten free. If you're not celiac, you don't need to be gluten free, but I do encourage you to buy organic, if it's wheat, because most wheat has been sprayed with glyphosate unless it's organic. That actually can cause harm to your microbiome. Nonorganic wheat being sprayed with glyphosate to me is problematic. I think that people need to make sure they're consuming whole grains. 98% of Americans are not getting the recommended amount of whole grains. When you look at the evidence on whole grains, they reduce our risk of heart disease, our number one killer, reduce our risk of cancer, our number two killer and people live longer when they consume more whole grains. I think we should be eating them. If it's not wheat, then it needs to be something else. So, you don't have to be a wheat-consuming person. That's okay. But if you're going to go gluten free, you need to make sure that you make an effort to replace the wheat or number one whole grain with something else. Quinoa, sorghum, teff, amaranth, brown rice, these are some examples of gluten-free whole grains that you could use as a substitute. You don't have to consume gluten. You do you need to consume whole grains. But the evidence on gluten is just a little bit more nuanced than what we've all been led to believe.

Melanie Avalon: Okay. So many questions. I'm so glad that you brought up that study, because I was really, really fascinated by that. And so, I went and looked at it, and my understanding and interpretation of it was that because they had people consuming all the different things and seeing how they were reacting. It was that some people did react more to the gluten, but it was a much smaller percent. And then some people reacted more to the placebo, some people to the, is it, fructans, fructans? My takeaway-- I think at the end, they were saying that it also didn't account for the combination. We don't know maybe there's something to having both for fructans, fructans and gluten together, that's a problem for people? The takeaway for me was that it's definitely much more nuanced. And maybe people who think they're reacting to gluten might actually be reacting to fructans. But then there were some people in the study who did react more to the gluten. So, is it possible that it's just more nuanced and gluten is still a problem? I think it said in the study that the people who were just reacting to the gluten, those are the people that we would consider to have nonceliac gluten sensitivity. But that it's a much smaller number than we thought because going into it, they probably thought that everybody in this study had nongluten celiac sensitivity.

Dr. Will Bulsiewicz: Yeah, totally. I think that what this study does is, first of all, it introduces the idea that maybe it's not the gluten, maybe it's the fructans. I think that there's value in saying that because it feels for the last 10 years, all we've been talking about is how gluten is so bad. 

Melanie Avalon: It's all gluten. 

Dr. Will Bulsiewicz: Right. It’s all gluten. Yeah, it’s the gluten monster. The gluten monster’s out there to get us. It's like whatever you do, you got to run away from gluten because it's going to come and get you. But the evidence that gluten is actually causing harm to us is really very thin. Where is the study saying that people who consume bread have more disease? Where is this study? It doesn't exist. Again, I'm not saying, we should consume more white bread, and more junk like ultra-processed foods. No, I'm not. I'm saying that high-quality sources of whole wheat, organic sourdough bread, these can be a part of a healthful diet. So, there is nuance to gluten. In my book as you know, Melanie, and I didn't touch on this yet, but I'm touching on it right now. There are some people who consume gluten-containing foods and they do have a reaction to them. That can include rash or other untraditional symptoms. We're not totally sure what the story on that is yet. I still wonder this is speculation. I still wonder if a lot of the weirdness around gluten is in fact weirdness around glyphosate. That's what I wonder. Because it's all been sprayed and unless, you go out of your way to buy organic, it's been sprayed.

Melanie Avalon: I mentioned earlier, I am making magnesium as my next supplement. But my supplement partner and I, we had a lengthy conversation about this the other day, because his theory is, it's the glyphosate. I have some more questions about the gluten. But first, I just want to say, I think this conversation is so valuable, because I know historically me and still, I guess, a lot of my listeners do exist within this paradigm of it's all gluten. And so, listeners, even if you don't agree completely with this new idea that we're positing or presenting, I think it is really helpful just to be open to a new perspective. And so, it might just be the first step in realizing, “Oh, maybe it's not as black and white as we thought.”

Dr. Will Bulsiewicz: Or, we're constantly evolving, right? I'm a big believer that my job is not to dig a trench and defend a position. My job is to ride the horse of science. And so, I will continue to evolve. If new evidence comes out that suggests that I need to reposition myself, I will do that. I'm not here to force a piece of bread down anyone's throat. But I do think that people living in fear have a healthy slice of sourdough bread. They don't need to do that. I feel we've been fear mongering this topic a little bit too much. Flipside, if you are sitting there and you're going, “Look, but Dr. B, here's me--” Because there's always these people, Melanie who come out of the woodwork and they always have an individualized story of, “Yeah, but when I eat gluten, blah, blah, blah, blah, blah, blah, blah.” I always say, “Yeah, you're right. You should not consume gluten, go gluten free.” What I'm saying to you is, “If you feel compelled to be gluten free, don't feel bad. It's all good. We're friends.” But what I'm proposing to you is that what I see is the two main choices here. Are either to include some high-quality gluten-containing foods or alternatively to go gluten free with an emphasis on gluten-free whole grains? You know what, honestly, Melanie, if it's okay, I'd love to throw a quick comment on why that is, real quick. 

Melanie Avalon: No. Please do. 

Dr. Will Bulsiewicz: Okay. This is not an inconsequential topic. My responsibility as a medical doctor is to try to guide people towards better health. If there's one condition that I should be guiding people away from it, it should be the number one cause of death in the United States and that's heart disease. More people die from heart disease every single year than there are people who die from COVID in the worst year of the pandemic. We need to have a consciousness about this where we are making smart informed choices that we lead us further away from heart disease. One of the studies that I talked about in the book, I don't know, if you've looked at several of these, Melanie, and I'm very impressed. One of the studies that I talked about in the book is that they looked at people going gluten free and their risk for having coronary artery disease. They took two populations. One is the celiac population. What happens when they go gluten free and their risk of coronary artery disease? The answer is, their risk of heart disease decreases substantially. Because when they consume gluten, it activates inflammation in their body and inflammation is what ultimately leads to heart disease. So, that is a great choice for them. 

But on the flipside, what happens to the person who does not have celiac disease and they go gluten free? The answer to that question is that in that study, they found that people had an increased risk of having coronary artery disease. You're actually exposing yourself to a heightened risk. Why? Again, this comes back to the nuance of how I present this. The reason why is because whole grains protect us from heart disease in a very powerful way. And so, my message is, you need to consume whole grains. And the choice is, either high-quality sources of gluten-containing foods or alternatively gluten-free whole grains. But I want you consuming whole grains because of this type of evidence that's suggesting to us that you are increasing your risk of coronary artery disease a number one killer, if you go gluten free and don't properly adapt your diet. 

Melanie Avalon: That's really interesting. 

Dr. Will Bulsiewicz: It's a big part of what motivates me to put this message out there. I'm not trying to pick a contrarian perspective. I understand this is contrarian to what has been very common popular diet conversation around gluten for the last eight years or so. I understand this as a contrarian point. I'm not trying to be contrarian. I'm using my education and my experience, and I'm looking at the studies, and this is what I see. Part of what I see is, when the entire world is going gluten free and they don't need to, are we putting ourselves in harm's way in the long run when we do this? I just want to make sure we're making smart choices.

Melanie Avalon: Going back to the Hadza, for example, do they have high heart disease?

Dr. Will Bulsiewicz: The life expectancy of the Hadza is not 90. There's a lot of complicated reasons for that. They don't have access to healthcare the way that you and I do. The Hadza also consuming extremely high-fiber diet. The average woman in the United States right now gets about 15 or 16 grams of fiber per day, the average man gets about 18 grams of fiber. The recommended amount for a woman in the US is 25, the recommended amount for a man is 38. And the Hadza, most of what I've seen, they suggest that they consume about 100 grams of fiber per day. It's not that you need whole grains necessarily. I don't think that they do consume a lot of whole grains because they would need to be growing the product. I don't think that's something that you forage. But it's not that you necessarily need to have whole grains. But when we look at the American society, we are not the Hadza. So, trying to activate what our perception of their diet is, but then sleeping in our bed and hopping in our car to drive to work, we're not really doing it. [chuckles] You know what I mean? We're not living that life. They're running around. But they do consume a high-fiber diet. And we do know from my personal favorite fiber study of all time which, by the way has been mentioned in both of my books. My favorite-- [crosstalk]

Melanie Avalon: The Lancet or that was a review?

Dr. Will Bulsiewicz: Yeah, The Lancet 2019, Andrew Reynolds. Thank you. I'm so impressed. This is amazing. 

Melanie Avalon: [laughs] I love all this stuff. 

Dr. Will Bulsiewicz: Okay. The Lancet 2019, Andrew Reynolds, one of the benefits of increased dietary fiber consumption is a reduced risk of heart disease, a reduced risk of death from heart disease. And so, these Hadza that are consuming 100 grams of fiber per day and they're not exposed to ultra-processed foods at all. Think about that. That's a very healthy diet. It doesn't matter to me whether what label we apply to it. That's a very healthy diet.

Melanie Avalon: Do you know if there's been any studies comparing a whole foods plant-based diet with or without grains?

Dr. Will Bulsiewicz: There was a study that was done-- I mentioned it. I do get pushback on this, because obviously, if people's dietary preferences they feel has been disrupted, then they're going to try to push back. But there was a study in Australia, where they compared to a standard Australian diet to a paleo diet. What they did with the paleo group is they broke them into hardcore paleo versus more loosely paleo like paleo-ish. They looked at their TMAO level.

Melanie Avalon: Oh, God, I'm so glad we're talking about TMAO. Okay. [giggles] I'm excited.

Dr. Will Bulsiewicz: Okay. TMAO is a compound that is produced when the gut microbiome is exposed to carnitine specifically, and in some cases, choline. You need the gut microbes in order to activate it. If you don't have the right microbes, you can't produce TMAO. The microbes will produce TMA, which goes to the liver and the liver activates it to TMAO, and then TMAO has been associated in research at the Cleveland Clinic, which is our number one cardiovascular heart center in the country. It has been associated with increased risk of heart disease, increased risk of congestive heart failure, increased risk of stroke, increased risk of chronic kidney disease. TMAO is this independent cardiovascular risk factor that we're concerned about. And so, in this paleo study out of Australia, they compared paleo to a standard healthful Australian diet. They discovered that in people who consume a paleo diet, they have increased TMAO levels. And these TMAO levels actually increased substantially when you went from a paleo light up to a hardcore paleo diet. You actually increased your TMAO substantially more, which if the Cleveland Clinic is right that suggests that you're substantially increasing your likelihood of having coronary artery disease down the road. 

Now, it was not like a meat-based thing. Because if you look at the breakdown of the study, the amount of meat that was being consumed in both groups was very similar. Instead, when the author's performed their discussion and analysis, what they discovered is the reason why the paleo group that was super hardcore had this cranked up TMAO level was because they were truly serious about restricting their whole grains. They actually identified in this study the microbe that was specifically associated with whole grain consumption that was protective. When you consumed whole grains, you got more of this microbe and that microbe helped protect you against TMAO getting activated, even though you're eating red meat. And the absence of the whole grains actually was what they believed to be the bigger problem.

Melanie Avalon: Quick tangent from that. I think you also referenced a study about red wine reducing TMAO. 

Dr. Will Bulsiewicz: Yeah, we think that red wine, [chuckles] we celebrate that, don't we? [chuckles] Red wine, we believe red wine, we believe that balsamic vinegar, I believe possibly extra virgin olive oil as well. And so, when you start to hear those things, red wine, balsamic vinegar, extra virgin olive oil, what comes to mind? For me, it's a Mediterranean diet. This is probably part of why a Mediterranean diet can be such a healthful diet.

Melanie Avalon: What are your thoughts on, because I was researching TMAO more and I found a really interesting study, actually, recent from March 2022. It was called Diet, Fecal Microbiome. and Trimethylamine N-Oxide in a cohort of metabolically healthy US adults. It was proposing that TMAO could be elevated in healthy individuals. But maybe in that context, maybe it wasn't a problem. What are your thoughts on that idea?

Dr. Will Bulsiewicz: Well, I think we're unpacking it. We have multiple cohort studies from different populations that have found this association that doesn't etch it into stone. Obviously, we want to continue to learn more. There are studies where in an animal model, they'll inject TMAO into an animal and actually see increased clotting, which would suggest that this is not just a co-associated marker, but instead, actually directly associated with what's going on. I think that one of the challenges, Melanie is that there's this nuance to clinical research where you can do-- Even when it came to smoking and lung cancer, there were studies that suggested that smoking was protective and that's crazy, right? Because we all accept that smoking causes lung cancer. We all know that's true. But in that moment, there were some studies that said otherwise. 

And so, it becomes important is to not seek out the one study that indicates that something different, but instead to look at the totality of the work. This is why we can't just pull one study. We have to look at the totality of the work and try to add an interpretation to that. That's why it's hard and complicated. I, not only conducted clinical research myself and published papers, but I actually did night school in order to get a masters of clinical investigation and a big part is, frankly, just to understand what's going on in these things.

Melanie Avalon: Speaking to that, I'm looking at the big picture. What do you say when people argue the grain correlation is pretty much correlational? Healthy user bias? Yeah, a lot of people will just say that it's a correlation thing.

Dr. Will Bulsiewicz: So, no offense to anyone, but I don't see people who are trained scientists saying this. What I tend to see is people who have entrenched position on topic and the entrenched position is under attack because of a population-based study. Then it's the almost knee jerk response to the population-based study is, “Well, this is correlation, not causation.” The problem is that we have to understand that there are different roles for different types of studies. There are many types of studies and we want all of them. I am not here arguing that the only thing that matters is population-based research. But we were just talking a moment ago about how smoking causes lung cancer. Do we believe that? I hope so. That's population research. We wouldn't know that without it. There's never been a randomized controlled trial of smoking and lung cancer that doesn't exist. So, how did we learn so much about COVID so quickly? It was population-based research. Is it perfect? Of course, not. It's imperfect. 

We're constantly trying to do better. But we do have quite advanced methods that we use. This is not quite simply just a correlation. These are correlations, where we control for confounding factors, we're doing everything within our power to try to eliminate those types of things. It's imperfect. There are things like healthy user bias, but to discredit the entirety of population-based research from my perspective is to effectively say, “Well, smoking does not cause lung cancer.” There's never going to be randomized controlled trials on many of these complex topics, where the medical condition takes a long time to develop. Latent diseases that take decades to develop. You can't do randomized control trials for that. So, what we need is, we need a combination, like, what we should be looking for is, we want to look at the whole body of work that includes these preclinical studies. It includes the animal model studies or test tube studies. And then it also includes randomized controlled trials and population research. What is the direction that it's pointing us? When you see consistent messaging emerging from that, that's when you know that you're really on to something very powerful. 

The reality Melanie is that these topics, people want them to be black and white. But debate and discourse has always existed. It's always been there. If you went to a medical meeting 50 years ago, you would see people yelling at each other. It's just that the debate has now spilled out of the conference hall and into the public. We also have people sharing their opinion on the internet. I guess, we all have the right to do that. That's part of the challenge. I think that to me, I personally find that if a person is categorically dismissing all epidemiology and population-based research, then I don't think they understand the nuance of research.

Melanie Avalon: Well, I will say, for me personally, this was actually the second time in recent history where I definitely saw my brain changing its paradigm. Recently, I interviewed Dr. Neal Barnard and we talk a lot about soy. When I dive deep into soy, I started changing my mind about what I thought about soy. And then reading your book, when I try to be as unbiased and uncherry-picked possible, especially, if I know I have a preconceived notion about it, I go to Google Scholar, I type in the topic, and I try to just look at what comes up without any preconceived conception. I did that with grains and inflammation. I was like, “Oh, it's actually--” If you really had no preconceived notions and you just google the things in Google Scholar like grains inflammation, grains heart disease, grains whatever, you would make the argument that whole grains at least are supportive of health in that aspect at least from my opinion.

Dr. Will Bulsiewicz: Yeah, I get that. Let me just say, first of all, I welcome that we all have differences of opinion. There're things that I disagree with Neal Barnard about, and we all are coming at this, and we're all doing our best. Where I'm at is when someone describes it the way that you just described it like, “Hey, I know that I have my biases, and I'm trying to be open-minded about this, and I'm willing to evolve,” I give a standing ovation to that. Because I think that that's so different than what the world has become in 2022, where we just want to throw spears at each other from our entrenched position. And it's like, “No, we need to have discourse, and conversations, and respect one another, and continue to love one another, and not be just shouting.” 

But yeah, I think whole grains and legumes to me, it's very hard to say that they're inflammatory, when the healthiest populations in the world, the basis of their diet is whole grains and legumes. We have overwhelming evidence that in both cases, less risk of heart disease with less risk of cancer among other conditions.

Melanie Avalon: I just want to say, I can't agree more with what you just said about people being open minded. This is just so important to me. I do, though. All that said, I am really happy because I actually, well, I don't know if I should be happy, but I've existed in the gluten-free paradigm for so long personally practicing a gluten-free diet. But I do have a wheat allergy like an IGE wheat allergy, which is one of your categories, I think.

Dr. Will Bulsiewicz: Yeah, and most people, like, if you have a wheat allergy, then you shouldn't be eating wheat. That's a wheat-specific thing. That's not gluten-specific thing, but that's not-- Any food allergy, we have to be careful.

Melanie Avalon: Quick question about the celiac diagnosis, because I've also been doing gluten free for so long. How long do you have to be consuming gluten for it to show up on a biopsy?

Dr. Will Bulsiewicz: It's a little bit brutal. I apologize. I wish it was a little bit easier than this just is what it is. Typically, we recommend at least two weeks of at least one slice of bread per day. 

Melanie Avalon: Okay. But if I had a wheat allergy?

Dr. Will Bulsiewicz: If you had a wheat allergy, then what you would probably need to do is you would have to focus on rye bread or barley, eating barley every day.

Melanie Avalon: Maybe before my fourth colonoscopy, which will be. My next one will be my fourth. Well, I want to be super respectful of your time. I was wondering if there's one more topic, I can ask you about. We've touched on it a lot. I have a nice study to open it. But we've touched a lot on the role of fermented foods and I loved the section on fermented foods in the book. I am like you when I discovered the magic of home fermentation. It is just so fun, so exciting. But what are your thoughts on the recent, sort of recent study that came out, I don't know, a few months ago, maybe about fermented foods versus fiber in--? Did you see this and how it affected people's inflammatory markers? 

Dr. Will Bulsiewicz: Of course. These are my friends. 

Melanie Avalon: I was wondering what your thoughts are on that study and also just the role of fermented foods in general in our gut health.

Dr. Will Bulsiewicz: Yeah, so, lets’ talk about fermented-- This is a two-part study and it's something worth people checking out. This is coming out of Stanford University. It was published last summer. A couple of my friends, Professor Christopher Gardner is someone who's on the ZOE Scientific Advisory Board with me and Justin Sonnenburg, if you look at Fiber Fueled, he supported my book. And so, in this study, they were looking at a dietary intervention and how it can affect your gut health over a period of 10 weeks. One of the interventions was to have people increase their fermented food consumption. I'm going to talk about the fiber more in a moment. When people increase their fermented food consumption, what was exciting is that after about 10 weeks, they actually increase the diversity within their gut microbiome and there were reduced measures of inflammation. So, that's really very exciting. Because I, in 2020 wrote Fiber Fueled touting what I believed to be the benefits of consuming fermented food. And it's the summer of 2021 that the study comes out that now says like, “This is potentially a gut health game changer.” In this study, people were not consuming fermented food at baseline. If they were, it was yogurt for some people a couple times a week. That was it. 

One of the things that I think was going on here in this study is that, first of all, fermented foods can be great, because they include live bacterial life microbes or living food. But they also can include fiber and prebiotics. Many people are not consuming these foods. The idea that I've been preaching throughout our episode today is, we need abundance. We need variety. We don't want to restrict our diet. We want to expand. In this study, the expansion of their diet into a food category that they were not previously consuming led to benefits to their gut microbiome in the course of just 10 weeks. I think we should all be eating fermented foods. It was in my first book, but it's here in my second book, The Fiber Field Cookbook that I actually am able to give you the recipes that you need to accomplish this. So, there's an entire recipe section for that all fermented. An example would be fermented salsa. It's going to blow your mind.

Fiber, I'm going to guess that the majority of your listeners, I know, the discourse and conversation that's occurring around this and let me guess, though, that the majority of your listeners haven't heard about what happened with this part of the study. In the study, they basically told people, “Crank up your fiber.” What you did is, you took a population of people that were consuming on average about 20 grams of fiber per day. Over the course of just a couple of weeks, they more than doubled that to about 45 grams of fiber per day. That's a lot. There were some people in the study, there was a subsegment that struggled to do this and there was some increased inflammation in these people. When you look at these people or this subset, there is actually a consistent discovery that their gut microbiome at baseline was not healthy. Now, I am not surprised by the findings from this study. This is not a curveball, and this is not a gotcha in any way. People who have a damaged gut microbiome are going to struggle to increase their fiber. That's something that I've been very upfront about because when you consume fiber, it is so good for your gut microbes. But for people who have a damaged gut, it's putting a strain or a stress on your microbiome and it can be hard. 

For a person who has a damaged gut to go from 20 to 45 grams of fiber per day in just a couple of weeks, I would never advise that. That is not low and slow. That is aggressive and over the top. And I'm not surprised that they struggled in this particular study. It's not proof that fiber does not work. I think it's very worthwhile people who claim that the study indicates that fiber does not work, they should go look at the recommendations that are coming directly from the authors of the study. Go, check out what Professor Christopher Gardner or Justin Sonnenberg recommend. They both have been on plenty of podcasts. What you're going to hear them continue to recommend is a high-fiber diet.

Melanie Avalon: What was the equivalent, so, the amount of fermented foods that people have to eat for those benefits? Is that a small amount? 

Dr. Will Bulsiewicz: Well, one of the keys is to understand that a serving of fermented foods is very small. You don't need to be eating a bowl of sauerkraut to have one serving. Literally, a tablespoon or two of sauerkraut would count or four ounces of kombucha. And so, in this study, people went from less than half of a serving of fermented food per day up to I believe it was five or six servings per day. It's a bit aggressive. It's not necessarily easy to do that unless you're really being focused on it. But I think what you look to do is you look to incorporate fermented food into meals wherever possible. I think fermented foods make a great garnish. You can work them into a lot of different things when they're not the centerpiece of the dish. There's something that's on the side and you're enjoying as a complement to the dish.

Melanie Avalon: I love that you pointed out that there's never been a case of food poisoning linked to fermented foods. I thought that was really interesting, because there's definitely a fear, I think that, especially if you're home fermenting that there might be some sort of issue. Sounds like they're relatively safe.

Dr. Will Bulsiewicz: I think so. I think they're relatively safe. We always want to play it safe, but you can have food poisoning from getting a Jimmy John's sub. [chuckles] There's no way to make yourself completely separated from risk in your life. You just hop in your car every day and the majority of accidents that occur, occur within a couple miles of your house. And so, I think the thing with fermented foods and this is also true of sprouting is, you want to take the appropriate and necessary safety precautions. When it comes to fermented foods, if you're not really sure or not really comfortable with it, just buy it at the store, like, buy your kombucha at the store, you can buy sauerkraut, or kimchi, tempeh, miso. When it comes to sauerkraut, don't buy it in a can. If it's in a can, not fermented. It needs to come in a jar, and it needs to say live active cultures, and then you know you're on to something.

Melanie Avalon: Speaking of the live active cultures, if it's dead, does it still have effects? Because I know there's really fascinating studies on dead probiotics still having beneficial effects.

Dr. Will Bulsiewicz: Yeah. We suspect that it's not the life of the bacteria that matter exclusively. Part of it is that the bacteria can have byproducts. There are the probiotics which are the bacteria. There are the prebiotics which are things like fiber or polyphenols. And then there are the postbiotics, which are the things that the bacteria produce. Things like butyrate, acetate, propionate, the short chain fatty acids that I like celebrate and love, those are produced by microbes deep inside our colon. But when you make fermented food, there's an ecosystem of microbes within that fermentation that are basically working on what is there. Whether it’d be cabbage or whatever it may be, and they're transforming the food, and they’re creating new products including they make new forms of fiber called exopolysaccharides. And so, to me, when I hear the word, fermentation, the first word that comes to mind is transformation like you are transforming your food.

Melanie Avalon: They can even make melatonin?

Dr. Will Bulsiewicz: Yeah. [chuckles] The microbes, but also just food in general, its mind blowing. In the cookbook, I talk a lot about sprouting. Sprouting could be medicinal. People who have histamine intolerance, which you and I didn't really talk about in great detail today, but it's a form of food intolerance that's more common than people realize. One of the ways that you can combat histamine intolerance is by quite simply eating sprouted peas. Because sprouted peas actually have the enzyme that our body needs to break down the histamine. 

Melanie Avalon: They’ve DAO in them?

Dr. Will Bulsiewicz:  Yeah, DAO, diamine oxidase. Yeah. Another cool thing, Melanie. Again, naure, yo, nature, you are crazy, you are amazing. When you sprout these peas, if you do it in the dark, the darkness actually puts a stress on these peas and that stress brings out the best in them, and you get higher levels of this enzyme DAO. So, sprouting your peas in the dark is the way to do it if you have histamine intolerance. 

Melanie Avalon: Oh, wow. I was actually wondering that about white asparagus if it had extra benefits because it's created in the dark. I was wondering that about white vegetables.

Dr. Will Bulsiewicz: So interesting. Yeah, I don't know. Obviously, there are some white vegetables that are very healthy. Usually, we stay away from white stuff., but really, we mean like sugar and white flour but--

Melanie Avalon: Do you know Farmer Lee Jones? 

Dr. Will Bulsiewicz: Yeah.

Melanie Avalon: We had a long conversation about the white asparagus. He was like, “Nobody's ever asked me that.” [laughs] But I just think it's so, so cool. He's the most inspiring person [giggles] in the world.

Dr. Will Bulsiewicz: His book is, to me, it was beautiful and it's exciting. I think it was just a triumph. The problem is that, if books are too expensive, people don't buy them. And his book was very thick and that’s because he put so much time and effort into it, it was really great. 

Melanie Avalon: It's so heavy because I take selfies with the books to put on social media and I was tired holding it up. I was like, “I can't take any more selfies. [laughs] 

Dr. Will Bulsiewicz: It's a workout, challenging your bicep.

Melanie Avalon: I know. Well, this has been absolutely amazing. Honestly, one of my favorite conversations that I've had on the show and I just can't thank you enough for what you're doing. I really, really appreciate the nuance and the detail on the science, and especially just how approachable and open minded you are. I just think it's really, really valuable. So, that's actually perfect. The last question that I ask every single guest on this show and it's just because I realize more and more each day how important mindset is. So, what is something that you're grateful for?

Dr. Will Bulsiewicz: Grateful for my wife. We have three kids, new baby. She carried that baby for nine months. This life that I have and all these exciting and wonderful things that are happening for me, none of it would have been possible without her. I recognize that this is not about me, this is about the people who support me and make me a better person and I'm very grateful for that. 

Melanie Avalon: Well, I love that so much. I have to ask you, ever since publishing your book, how many people have randomly come up to you and what do you say like to high five you or handshake and say “Fiber is fire?” Do people do that to you?

Dr. Will Bulsiewicz: Well, the problem is, when you publish a book in the middle of a pandemic, people stop giving high fives, which I love high fives. I like top secret handshakes. But I have had a lot of people say, “Fiber is fire” and I do appreciate that. It really is pretty cool.

Melanie Avalon: I love it. Well, thank you, again, so much. This has been amazing. I can't wait to read your cookbook. Oh, my goodness. Hopefully we can bring you back in the future again, because I could ask you like a million more questions. So, thank you so much for your time.

Dr. Will Bulsiewicz: We won't so long this time and I promise to not be so elusive, Melanie. So, thank you.

Melanie Avalon: It was not you.

Dr. Will Bulsiewicz: Yeah, I do appreciate everyone hanging out with us for this nice conversation. In the closing moment, I just want to say one last thing, which is that, I recognize that you have a diverse mix of people who eat different diets and they listen to this. I just want people to know I realize I'm saying this in the very end, but I don't want you to feel I'm asking you to eat the way that I eat. I want you to eat the way that you want to eat. I want you to find the same joy in your food that I find in my food. But I also want it to be done in a way that lifts you up and brings you great health by optimizing your gut microbiome. And so, that's what I'm hoping to accomplish with all these things that I'm doing. For example, my books,

Melanie Avalon: Thank you so much for emphasizing that. Because that is truly my mission with this show is to do exactly what you just said. So, thank you. Thank you, thank you. All right. Well, I will talk to you again in the future.

Dr. Will Bulsiewicz: Perfect. Thank you, Melanie. Thanks, everyone. 

Melanie Avalon: Thanks. Bye.

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