Why are we so awkward about poop?: Transcript

Dr. Jen Gunter:
When we're kids, we have a beautiful gift.

Rosie:
Why does poop smell bad?

Wylder:
Because of its things inside.

Rosie:
Yeah. Like diseases.

Wylder:
Diseases.

Dr. Jen Gunter:
We can talk freely and happily about something we all make, poop.

Rosie:
I have red poop and green poop.

Dr. Jen Gunter:
But when we get older, all that laughter turns into embarrassment. So when we have questions or concerns about our poop, "Why is it hard for me to go? Does my poop smell really bad? Am I pooping the wrong way? Do I not poop enough? Am I pooping too much? Am I constipated? What does that even mean?" We often let those questions fester and myths can seep into the gaps left by unanswered questions. Myths prevent you from having a real understanding of how your body works. They can leave you vulnerable to bad advice, worrying about things you don't need to worry about and even missing real problems.

Today, we're taking on poop and the digestive system. Look, there's nothing shameful about your body, not one part of it. And it's healthy to talk about it and to learn about it. I'm Dr. Jen Gunter. From the TED Audio Collective, this is Body Stuff. There's one myth I hear all the time, that you have to poop once a day. Otherwise, you're constipated and something is wrong and something bad might happen to you. But there is no magic number, for number two. Everyone is different. Anywhere between three bowel movements a day to three a week is typical. There are a lot of other poop myths out there too, and they thrive in our shame and embarrassment. And one way to clear them up is to get comfortable talking about poop.

Dr. Anish Sheth:
My father in particular was always very open and I would say overly enthusiastic about discussing bowel habits at the dinner table.

Dr. Jen Gunter:
That's really interesting because I got into gynecology probably for the exact reverse. My mother was the biggest prude in the whole world and we never ever talked about anything sexual at all.

Dr. Anish Sheth:
We all have our different inspirations.

Dr. Jen Gunter:
I know, right? Inspiration can come from anywhere. Dr. Anish Sheth is a gastroenterologist, a specialist in everything from your esophagus to your stomach, to your intestines. And he's building on the family tradition. He wrote a book called What's Your Poo Telling You? Dr. Sheth says there are a lot of fascinating things to learn about your poop, like one reason why coffee might get things moving.

Dr. Anish Sheth:
It's actually something called chlorogenic acid, which is a component of coffee, which itself stimulates the movement of the intestinal tract.

Dr. Jen Gunter:
And what it takes to achieve something called poophoria.

Dr. Anish Sheth:
It's something that if we could bottle, I think would be a good thing for humanity.

Dr. Jen Gunter:
There are also mysteries about our gut, things we're just starting to understand, like the fact that your gastrointestinal track has over a hundred million nerve cells. Sometimes it's even known as the second brain and serotonin, a neurotransmitter that affects our moods, isn't just found in our brains.

Dr. Anish Sheth:
Serotonin is actually found in higher concentrations in our gut than in our central nervous system. So it is quite complex and I think we're just scratching the surface of understanding it.

Dr. Jen Gunter:
Let's start our journey to poophoria with the basics. Poop is a waste product. It's the end results of the digestive process. It's mostly water, but it's also made up of fibers, some dead cells from the lining of our intestines, mucus and bacteria. Some of the bacteria, really stinky gases, like hydrogen sulfide, which you might know as sulfur, giving poop its characteristic aroma.

Dr. Anish Sheth:
These are things that are byproducts of the food that we eat, the digestive process, things that we no longer really need. And so the body very efficiently and maybe elegantly gets rid of it, and that's what we call stool or bowel movements.

Dr. Jen Gunter:
Things can go wrong and the digestive process, and that can cause a lot of pain, discomfort and suffering. Because people are often squeamish talking about their bowel movements, they don't always bring up these concerns with the doctor. One survey of Americans with the gastrointestinal condition, irritable bowel syndrome, found that 67% of them waited more than a year after the start of their symptoms to even talk to a doctor.

Dr. Anish Sheth:
As a gastroenterologist, it's a little bit disheartening because you sort of feel like, this person unnecessarily suffered when we could have intervened earlier and maybe things would be better than they are now. And it just sort of speaks to the stigma, sometimes people feel that exists around things related to your gut.

Dr. Jen Gunter:
And when people do bring up their concerns, you know what, they're often dismissed. A report from the United Kingdom found that a third of people with the bowel disorders, irritable bowel syndrome and inflammatory bowel disease, had to visit their doctor more than five times to get a diagnosis. So today we're talking about our poop and what we can learn from it. But we're starting with something I've always wondered about. What's the origin of the shame?

Dr. Barbara Penner:
Look, we love to blame the Victorians for everything, for all of our weird hangups.

Dr. Jen Gunter:
Dr. Barbara Penner is an architectural historian. She wrote a book called Bathroom. It's about how toilet design and our ideas about poop have shaped each other over the centuries. Dr. Penner took me back to a time in England when most people didn't use indoor toilets. Those are only for the very, very rich, darling. Instead, most people used outhouses.

Dr. Barbara Penner:
If we look at pre-modern times, let's say pre 18th century, there are loads of examples of two and three cedar outhouses.

Dr. Jen Gunter:
Seats for people to poop side by side.

Dr. Barbara Penner:
And these really remind us that there just was not the same sense of shame around bodily functions. And we know that for many people, going to the toilet could even be a time for socializing.

Dr. Jen Gunter:
That's awesome. Imagine pooping next to your best friend or your mom or your neighbor. Instead of sitting on the stoop catching up, people were sitting on the toilet chatting. It's where you caught the local gossip. And that was totally normal until the 19th century, the Victorian era in England. That's when indoor plumbing became much more available in England and the US, and it's when we learned more about how diseases spread. The British became obsessed with sanitation.

Dr. Barbara Penner:
The Victorians surely must go down in history is some of the greatest cleaner-uppers of all time. They zealously pursued sanitary reform, they constructed infrastructural projects like London's sewer system.

Dr. Jen Gunter:
But for the Victorians, Penner says, it was about more than just hygiene.

Dr. Barbara Penner:
It became almost a moral imperative to distance oneself from sources of dirt or contagion. And the body itself became deeply shameful.

Dr. Jen Gunter:
All that Victorian shame even affected where women could use the bathroom. Proper women weren't supposed to just sit their delicate down and poop anywhere.

Dr. Barbara Penner:
It was quite common to hear female public conveniences described as abominations. The people who actually needed female public conveniences were female factory workers who were often commuting to and from their jobs.

Dr. Jen Gunter:
Right. So it's a clash of classism and misogyny.

Dr. Barbara Penner:
Definitely.

Dr. Jen Gunter:
According to Dr. Penner, the Victorians also popularized the actual physical bathroom design many people in the West are familiar with, a flushable porcelain throne that you sit on in a small isolated room. This was called a water closet. Remember, we're talking about the British Empire here. And at this time, it was huge and reached around the globe.

Dr. Barbara Penner:
So you find British made sanitary systems all around the world by the end of the 19th century, early 20th century and water closet became a symbol of civility. The absence of a water closet meant that you could very easily stigmatize people who went without, as being inferior.

Dr. Jen Gunter:
So when these first Victorian water closets came out, did people have toilet paper? What did they use to wipe their bottoms?

Dr. Barbara Penner:
They used strips of paper. This was also very conveniently the age of the mass produced newspaper.

Dr. Jen Gunter:
Maybe that's why reading on the toilet became a thing. Anyway, Dr. Penner says the water closet took off. Not because it's designed based on human physiology or science, but because it was championed by the most powerful empire in the world at the time. And when the British Empire spread its new invention, it also spread cultural ideas of poop shame. But the British porcelain throne design is not universal. It's based on sitting when we poop. But our bodies actually perform best when we squat. We'll get into this more later. It's important to point out that in many countries, toilets are actually made for you to squat rather than sit. Some places have adapted the British design. Like in Japan, toilets can be totally deluxe with heated seats and little songs that play while you go to cover up any noises you might make. And of course, there are bidets. You find bidets in bathrooms all over Europe, the Middle East and Africa. After you go, you use the bidet to spray off instead of toilet paper. And then there are the toilets you often find in Germany.

Dr. Barbara Penner:
They have a ledge so that poo does not fall straight into water, but rather it rests on this ledge and you can inspect it to make sure that you're having healthy stools.

Dr. Jen Gunter:
That's a literal Inspector Gadget. After the break, what looking at your poop, like some Germans do, can teach you.

Dr. Anish Sheth:
Look before you flush. A lot of people just take care of business and they'll flush, and I think they're flushing away real good information about their health.

Dr. Jen Gunter:
So now you know poop is a waste product. But you may wonder how it's made. Let's take a closer look at your digestive track. The digestive system is the long winding tube that runs from your mouth all the way down to your anus, plus a few extra organs that provide essential assists along the way. The digestive process starts when we eat something. We chew the food and our saliva softens it and starts to break it down. The food goes down to our esophagus, then into our stomach. It's here that the pieces of food are made smaller with acid and enzymes. And then those smaller pieces are then emptied into the small intestine. The small intestine, it's job is to absorb the nutrients from the food. It basically sucks up the good stuff that we need and the leftovers go to the large intestine. Here's our gastroenterologist, Dr. Sheth, again.

Dr. Anish Sheth:
And so by the time, this sort of debris, if you will, gets to the large intestine, which is also known as the colon. Really all the absorption of nutrients has taken place. So then we're just left with sort of the waste products, the byproducts of all this stuff.

Dr. Jen Gunter:
The stuff from the small intestine is pretty liquidy at this point. So the colon starts absorbing the water and packaging what's leftover, into stool. And then it sends it on down to the rectum. Another amazing thing about the colon, it contains trillions of bacteria. This is the microbiome that you might've heard about. A good analogy is a rainforest where a lot of different species co-exist and contribute to maintaining a healthy ecosystem. It's just in this case, it's bacteria creating a good environment for the gut. The bacteria in our colon help with digestion. They also actually produce vitamins like several of the B vitamins and vitamin K. And they seem to do a lot of other stuff that we don't totally understand yet.

Dr. Anish Sheth:
They may play a role in obesity, they may play a role in heart disease, even mood, things like depression. And I think this is really the most exciting aspect of gut health, is that the bacteria have evolved with us for tens of thousands of years and what we used to just think of as maybe innocent bystanders, maybe causing harm, now we actually realize they actually may have beneficial effects, not only to our GI health, but also to our overall health.

Dr. Jen Gunter:
I hear a lot about hacking your microbiome, by taking probiotics. But we really don't know enough about the microbiome to understand how to do something like that.

Dr. Anish Sheth:
What we do know is that if you sample the microbiome and characterize somebody's balance of bacteria and what types of bacteria they have, you'll see some things that cluster with certain conditions and people that have better overall health. You will see some things that are different in their bacteria profile. What we don't know is if I take some healthy bacteria by mouth, and if I can change this balance of bacteria, will it then have beneficial effects on my metabolism, for instance. And I think that's really where we haven't been able to show that. And I think in general, I think you probably realize as well that sometimes when things seem very simple and easy in medicine, it turns out it's not the case.

Dr. Jen Gunter:
It's such a complex subject that we don't know what we don't know about the microbiome. It's like a whole new world and we've just scratched the surface. But one thing we do know about is how to poo the fine art of deprecation. Deprecation is releasing poop from your body and it's actually a very coordinated, elegant process. The stool created by the colon makes its way to the rectum, a pouch right at the end of the large intestine. In the rectum, the stool builds and builds until it reaches a certain amount. That's when the rectum sends a trigger to your brain that says, "Hey, pouch is getting full. Maybe we need to empty this." So your brain makes an assessment. "Is this a socially acceptable time for me to poo, or maybe not?" Once your brain has assessed it's a socially appropriate time, the muscles around the rectum and the anus relax and release the stool.

Dr. Jen Gunter:
If it's not a good time, your brain sends signals telling your rectum to calm down, kind of like your rectum says, "Are we there yet?" and your brain's like, "Nope. Nope, not yet, not yet. Occupy yourself with something else." The anal sphincter is an especially amazing part of this process. It's a complex made of two muscles, the internal and the external anal sphincter. The anal sphincter has a ton of nerve endings. So it can detect the difference between gas and poop and communicate that information accurately to your brain. The lining of your anus, the muscles in your brain are all doing this amazing communication completely behind the scenes.

Dr. Jen Gunter:
The whole digestive process can take between 24 to 120 hours in healthy people. And because poop is a waste product, it has to leave your body. You've probably experienced how unpleasant it is when it doesn't. Constipation is a common poop problem. To help people understand what's going on when you're constipated, I like to use an analogy of a tennis ball in a pantyhose. Think of your poop as the tennis ball and your colon as the pantyhose. Constipation happens when the tennis ball doesn't get from one end of the pantyhose to the other, like it should. It could be moving too slowly, causing you to poop infrequently, or your poop could be hard and pebbly like a rock is trying to get through instead of a tennis ball, or both of these things could be happening at the same time. Constipation can also be caused by tight muscles in the pelvic floor that won't relax enough around the rectum for you to release the poop.

Dr. Jen Gunter:
There are a variety of treatments for constipation and what treatment you might need depends on the cause. Some examples are eating more fiber, taking laxatives, or even seeing a specialized physical therapist who can work on those pelvic floor muscles. We have a lot of good treatments for constipation, but unfortunately, there's a lot of bad advice online. For example, drinking more water isn't a treatment for constipation. And there are fake constipation cures you need to avoid like colon cleanses, special supplements, teas, pills, coffee enemas, that means literally injecting coffee into your rectum. It belongs in your cup. These are marketed all over the internet as things that will flush out toxins and waste from your colon. It's predatory quackery.

Dr. Anish Sheth:
It's absolutely not needed and it's actually potentially harmful because we talked about the benefits of the bacteria that are in our large intestine. And so when you go through this kind of cleanse on a regular basis, you are wiping out the good bacteria and you're changing the balance of the bacteria in your system.

Dr. Jen Gunter:
Once you defecate and poop comes out, there's a lot you can learn from looking at it. What can we learn about the texture of poo?

Dr. Anish Sheth:
Texture, want it soft, consistent, not overly viscous and thick, is really a sign of a good balanced, diet.

Dr. Jen Gunter:
In your book, you write about different kinds of poo. So what's a monster poo?

Dr. Anish Sheth:
Monster poo just means you're just having a large, huge bowel movement. When you have a monster poo, you can experience this sort of sense of joy and elation that we call poophoria, right? It comes from sort of distending the rectum, which we talked about as being a very sensitive area and then having it decompress in a single bolus stool as it comes out. And that sometimes just makes us feel great, like you want to high-five the first person you see when you come out of the toilet.

Dr. Jen Gunter:
That's pretty funny. And it's always good to have some well-placed humor about our bodies. But it's also important for us to recognize that our poo can give us signs that something is seriously wrong with our colon.

Dr. Anish Sheth:
If you see blood in the stool, you always should call your doctor, that's number one. But the second thing is really a sustained change in bowel habits, right? And that can run the gamut, right? So that can be consistency, it can be frequency, color may be even. If it happens for a day or two, it's not a concern. But if you notice that say you always somebody who went to the bathroom twice a day, and now for the past, say several weeks or a month, you're struggling to go twice a week for instance, any sustained change that doesn't have an obvious explanation should also be followed by a phone call or a visit to your primary care doctor or gastroenterologist. And I think if you keep those two things in mind, I think that really covers the spectrum and most of the serious conditions that we worry about in the gut.

Dr. Jen Gunter:
Colon cancer screening is also important. The latest guidelines in the US are that once you hit age 45, you should talk with your doctor about getting screened. If you have a family history or other risk factors, you may want to talk with your doctor about whether you should be screened sooner. There are two things that can really help you on your journey to poophoria. First, and this might sound strange to you, actually learning how to poop. Welcome to pooping 101, everything you need to know, but had no idea you should be asking.

Dr. Jen Gunter:
Tip number one, try not to sit on the toilet for a long period of time. This can disrupt the reflex for going to the bathroom. And when people sit for long periods of time, they might be tempted to strain, which you want to avoid because it can lead to hemorrhoids, which are swollen veins in your rectum. Hemorrhoids can be incredibly painful and really hard to treat, so prevention is key.

Dr. Anish Sheth:
I tell my patients is, look, if you have the urge to go, you should be able to evacuate in about five minutes or less. And if you haven't, you need to get up, walk around and do something else. And if you feel like you have to go again, that's still a better option than spending 30 minutes on the toilet.

Dr. Jen Gunter:
Tip number two: If you've had a bowel movement and you're not sure if enough came out and you're trying to resist the urge to strain, you could do some quick flicks, which you might've heard called Kegel exercises. That means contracting your pelvic floor quickly. So you do quick, quick, quick, three quick contractions that either push the stool back up into the rectum or push it back out and can take away the urge to strain for some people.

Dr. Jen Gunter:
Tip number three: You can also improve your pooping position. The ideal way to poop, biomechanically, is actually squatting because it opens up the pelvic floor and helps the muscles relax. Most Western toilets aren't designed for you to squat. So to mimic squatting, you can put a stool under your feet to elevate them a little, or you can bend over and grab your ankles. Don't grip hard though. This is sort of a spa relaxation grabbing of your ankles.

Dr. Jen Gunter:
Tip number four: Try not to wipe aggressively. You need to blot and go. A bidet is also a fantastic option and you can even make a homemade hack with a squirt bottle. The other big tip for your poophoria journey is to eat something truly heavenly, fiber. I'm a fiber evangelist. Fiber increases the weight and size of your stool and softens it, which makes it easier for it to travel along the colon and less scratchy on the way out.

Dr. Anish Sheth:
The classic low fiber diet causes this sort of, what we call pebble poo, right? These sort of small little particles that are resting on the bottom of the toilet. That's not very satisfying, right? So the opposite of that is when you can eliminate stool in a single piece. And that's usually in somebody who who's eating a lot of fiber.

Dr. Jen Gunter:
If you're eating insoluble fiber, which is one kind of fiber, you might notice something about your poop.

Dr. Anish Sheth:
We use this term in our book, Deja Poo, which is this notion that you're seeing remnants of food that you have eaten in the stool. So there are certain fibers that are insoluble and I've had many patients come in and say, "I think something's wrong with my digestion." But in reality, they just have a diet that's very high in insoluble fiber. And that's actually a good thing and there's actually nothing wrong with your digestive tract when you see things like corn kernels, for instance, in your bowel movement.

Dr. Jen Gunter:
Some types of fiber are also prebiotics, which basically means their food or fertilizer for the healthy bacteria that live in your gut.

Dr. Anish Sheth:
If your microbiome is your lawn, then the fertilizer would be sort of healthy diet high in prebiotics.

Dr. Jen Gunter:
Fiber has a lot of other benefits too, it lowers the risk of heart disease, diabetes, and certain cancers. But sadly, most Americans don't eat enough fiber. So to rough up your diet, look for high fiber cereals, whole grains, beans, and fruits and vegetables. There's only one downside to eating too much fiber.

Dr. Anish Sheth:
I have patients who come in and, "Oh my God, I feel bloated. I got so much gas." And then I go through their diet and I'm like, "You're eating 50 grams of fiber a day." So the downside, the only downside in my book of fiber, is that it just naturally, by the way it's digested, will produce a lot of gas.

Dr. Jen Gunter:
So my friends, fiber is tip number two for your journey to poophoria. This concludes our sweeping saga poop, from the mouth to the anus, from Victorians to modern day time. When most people think about poop, they think about shame and embarrassment. It's something they don't want to talk about, and that prevents us from learning things that can keep us healthy. So let's start talking about bowel movements like Dr. Sheth's dad did, and like Rosie and Wylder.

Wylder:
What happens when you don't poo?

Rosie:
It's impossible. You can't not poop.

Dr. Jen Gunter:
And please, while we're talking, think about eating a little bit more fiber. Next week on Body Stuff, you didn't learn about this in health class. And what you have heard about sounds like a horror movie, but actually it's a marvel.

Clip from next episode:
There's so much positivity at that stage of life. You, the person, are so complete at that phase of life, you lose some, you gain more.

Dr. Jen Gunter:
We talk about what menopause really is and why your grandma is even more amazing than you thought. So get the health education you missed right here.

Body Stuff is a member of the TED Audio Collective. It's hosted by me, Dr. Jen Gunter, and brought to you by TED and Transmitter Media. This episode was produced by Camille Petersen and edited by Sara Nics and Lacy Roberts. The rest of the team includes Alice Wilder, Gretta Cohn, Michelle Quint, Ban Ban Chang and Roxanne Hai Lash. Alex Overington is our sound designer and mix engineer. Krystian Aparta and Neeraja Aravindan are our fact checkers. And special thanks to the person who invented heated toilet seats. We're back next week with more Body Stuff. Make sure you follow Body Stuff in your favorite podcast app so you get every episode delivered straight to your device. And leave us a review, we love hearing from our listeners. See you next week.