Today, I have the honor of connecting with Dr. Robynne Chutkan, one of the most recognizable gastroenterologists in the United States. She is also the author of Anti-Viral Gut, one of the books I enjoyed reading most in 2022!
Knowledge of the microbiome dates back to the 1600s when Anthony van Leeuwenhoek observed bacteria in his dental plaque through a microscope. However, it has taken us several centuries to understand the interdependence and beneficial nature of those bacteria. The terms "microbiome" and "microbiota" are often used interchangeably. They refer to the organisms and genes that live in and on our bodies, predominantly in the GI tract. Those organisms include bacteria, viruses, protozoa, fungi, parasites, and archaea, which, despite their microscopic size, collectively weigh around four to five pounds.
Today, Dr. Chutkan and I dive deep into the physiology of the microbiome and discuss how that interplays with immunology. We discuss the benefits of hydrochloric acid, the impact of proton pump inhibitors and other medications on the health of the gut microbiome, and the role of dysbiosis and the Estrobolome. We get into how the pharmaceutical industry has influenced both medical practice and the outlook of healthcare providers, and we talk about the impact of sleep, exercise, stress, and alcohol on the gut. Dr. Chutkan also shares top tips from her anti-viral diet book on the best ways to support the gut. (One of her tips is to consume 30 plant types per week for a healthier gut microbiome.)
This show has been one of my favorite podcasts I have recorded in the last year. I hope you enjoy listening to it!
IN THIS EPISODE YOU WILL LEARN:
What is the microbiome, and why is it important?
Why do we need to understand the interrelationship between the oral microbiome, the gut microbiome, and the vaginal microbiome?
The importance of stomach acid.
How do proton pump inhibitors affect gut health?
The three big things that interfere with digestion.
How pharmaceutical companies have taken over medical education.
The role of statins in women.
The importance of the Estrobolome test.
The three different types of estrogens in the body.
Why exercise is an important contributor to gut health.
The net impact of low-quality sleep on immune function.
Dr. Chutkan shares her top tips for a healthy gut microbiome.
“It turns out that 70 to 80% of the immune system is actually physically located in our gut.”
- Dr. Robynne Chutkin
Connect with Cynthia Thurlow
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Robynne Chutkan
Books by Dr. Robynne Chutkan:
Books mentioned:
Why We Sleep: Unlocking the Power of Sleep and Dreams by Matthew Walker
Transcript:
Cynthia Thurlow: Welcome to Everyday Wellness podcast. I'm your host Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
Today, I had the honor of connecting with Dr. Robynne Chutkan. She is one of the most recognizable gastroenterologists working in the United States and she is the recent author of one of my favorite books I read in 2022, The Anti-Viral Gut. Today, we dove deep into the microbiome in terms of physiology, a bit about immunology and the interplay between both, benefits of hydrochloric acid, the impact of proton pump inhibitors and other medications on the health of the gut microbiome, the role of dysbiosis as well as the estrobolome, the influence of the pharmaceutical industry and how it has impacted medical practicing and our outlook as providers, the impact of sleep, exercise, and stress on the gut as well as the net impact of alcohol, and her top tips in The Anti-Viral Gut book in terms of how best to support our guts, and one top tip was that we need to be consuming 30 plant types per week for healthier gut microbiomes. This has been one of my favorite podcasts I've recorded in the past year. I hope you will enjoy this conversation as much as I did recording it.
Good morning, Dr. Chutkan, I've been so looking forward to this conversation.
Robynne Chutkan: Oh, I'm so thrilled to be here. Thank you so much for having me.
Cynthia Thurlow: Well, I've been able to again read your book for the second time, your most recent book, and I would love to really start the conversation discussing the physiology of the microbiome. This is something that I didn't learn a lot about when I was back in my medical training days, but it has kind of evolved over the last 20 years, and I'm sure it has greatly influenced the work that you do. And thank you for the wonderful work that you do in the books that you do. I think you bring such a fresh perspective, one that's really accessible. Let's talk about the importance of the gut microbiome and what it is, how it impacts, how we interact with our environment. And certainly, over the past three years, I think for many people, they probably have started to look a little bit more closely at how it impacts immune function and our health in general.
Robynne Chutkan: The first thing I'll tell you is that when I was in medical school and I graduated from medical school 30 years ago, so when I was there 34 years ago, we're all busy trying to figure out how to be as clean as possible. And I'm sure you remember that too. In nursing school, we're busy, let's sterilize everything and make sure there's not one germ anywhere. And while that's certainly appropriate for certain settings, like the operating room, for example, you want that to be as sterile as possible. It turns out that not only is that not important for our everyday life, it's a terrible idea.
So, we've actually known about the microbiome since 1600s when Antonie van Leeuwenhoek first looked at his own dental plaque under the microscope and I think was pretty aghast and was like, "Oh, my goodness." I think the actual term in the ancient medical journals is he saw little animalcules so prettily moving and he was looking at bacteria. But it has literally, Cynthia, taken us a few hundred years to figure out that these organisms are really very much interdependent, and they're primarily here to help us. So, we'll start just with a definition for some of your listeners who may be less familiar. I know you have a very sophisticated audience, but for those who are less familiar with what we're talking about, first of all, we generally use the term microbiome and microbiota fairly interchangeably. One is referring to the organisms, other is the organisms and their genes. But for the purposes of everyday discussion, I think it's fine to just say microbiome.
So, we're talking about all the organisms that live in and on our bodies, mostly in our GI tract. And we can't see them. Obviously, they're microscopic. We're talking about bacteria, viruses, protozoa, which are little one-cell organisms, fungal organisms. Those are important for our health too, parasites, all of these archaea, and if we scrape them all up, would weigh about four to five pounds, even though they're microscopic. And to put it in perspective a little bit, like, how many microbes are we talking about? If we take a drop of fluid from our colonic secretions, they're about a billion microbes in that one drop. So, a lot of organisms and I always like to point this out in medical school, there's all this hierarchy, like the neurosurgeons and the neurologists think the brain is most important organ, the cardiologists think it's the heart, the nephrologist thinks it's the kidneys, and of course, as a proud gastroenterologist, I have to say, of course, it's the gut. Look at where the gut is located. It is in the smack-dab center of our bodies and it is an engine for our entire body. So, to sort of comment a little bit on the great point you were making, that the gut, the microbiome is having a moment in the last 20 years, we have realized that the gut is a central organ with spokes going in all these different directions. The gut-brain connection, the gut-heart connection, the gut-kidney connection, the gut-bone connection, it is intimately linked to all of these organs. And to know more organs, is it more closely linked than to the immune system, the gut immune connection because the immune system is literally right there on the other side of the gut lining?
When you were in nursing school, when they talked about the immune system, I had no idea physically what they were talking about. I mean, did that make sense to you if you think back?
Cynthia Thurlow: No. Not at all. And in fact, I would say if you were to pick a body system that I know the least about, I would say immunology without question because it seems so intangible. Whereas the stomach I can touch and see, hopefully not touch, I can see, I can envision what it looks like, a heart, a brain. The immune system to me was that's very abstract. It didn't really make a great deal of sense other than I was at Hopkins at a time when it was the HIV AIDS crisis. And so, looking at immunity from that perspective, people that were immune compromised, I understood that. But beyond that, no, it seems very abstract.
Robynne Chutkan: And to circle back to the AIDS epidemic, I was in medical school in really the early 90s, and during my residency and now AIDS HIV has become sort of this chronic disease, almost like diabetes, but people were dropping dead left and right. I mean it was a crazy time. Young people, sure you remember, were coming into the hospital and were literally dying because a lack of a functioning immune system. So, I actually think that immunologists were sort of faking it a little bit back then. I don't think necessarily really you, [Cynthia laughs] but it was this ephemeral thing like these cytokines and cells floating around, but where exactly are they?
And so, it turns out that 70% to 80% of the immune system is actually physically located in our gut and it is right on the other side of the gut lining. I think sometimes the most incredible things in medicine are the simplest. So, this is the other thing about the gut that I was a practicing gastroenterologist for probably 20 years before this really occurred to me, that when something is in your gut, it's outside your body. It is not in your body. It's in this hollow 30-foot-long digestive superhighway that travels all throughout your body. In order to get into your body, it has to get absorbed through the gut lining, get into the bloodstream, get carried to a distant organ, etc.
So, the gut is actually this hollow conduit that is in contact with the environment and that is outside our body. And what is inside our body is the immune system. So, on the other side of that gut lining, the epithelial barrier, are all these immune processes that are happening and there's constant communication. Like those microbes are literally signaling, literally sometimes kicking the wall of the gut to say, "Hey you guys, mountain immune response."
So, once you sort of understand that physical location that 70% to 80% of the immune system is-- a lot of it in the small intestine along that gut border and that they're constantly communicating with our gut microbes. Then you start to see, "Okay, the gut lining is really important and the microbes are really important and the gut immune connection is really important." So, it took me a really long time too.
Cynthia Thurlow: I think for many of us, if you really reflect on that, they probably just assume it's just a tube that communicates across your entire body and just understanding that there are protective mechanisms in this alimentary canal that many of us take for granted. Much to the point when I was working in cardiology, I think many of my patients ate food. They didn't think about their food after that and they didn't think about the net impact on their digestive system, their cardiovascular system, their entire body systems unless they started having pain or discomfort or something wasn't moving properly. Then they would consider, "Oh, maybe it's something I'm eating that is driving some of these symptoms that I'm experiencing."
Now you alluded to the fact that we have beneficial and nonbeneficial microorganisms in the gut and everything in the body is really looking for a sense of balance. It's not all one good, it's not all bad. And so, understanding that our modern-day lifestyles in many ways can impact this very delicate balance between symbiotic and nonbeneficial bacteria. And I know we're going to talk about dysbiosis, which is one of those things I haven't been able to talk about on a podcast yet, so I'm really excited about that.
But talk about the way that we have this interaction between our digestive system and our immunologic function and how there's this crosstalk in terms of if we're exposed to a pathogen, something that doesn't belong, how does our body react to what does not belong? There's both a fast-acting immune response and then one that is a little more sophisticated and takes a bit longer to kick in.
Robynne Chutkan: Sure. So, there is your innate immune system that you're born with that responds fairly quickly, but nonspecifically. So, if you get a cut, for example, it will release white blood cells to sort of try and heal the injury. And then there is the adaptive immune system that is learned. So, for example, every single pathogen that we're exposed to our immune system keeps track and then will create a memory so that when we're exposed to it later on, we can react to it.
This is a basis for a vaccine. As you know, Cynthia, when you get a vaccine, you get a small amount of the substance so that your body's immune system is able to create some memory cells. And then when you see it again, you now have protection. You have antibodies, etc., to it. And so, you are immune. There are some diseases, some pathogens where we don't need a vaccine because we have natural immunity once we're exposed to it, our body is able to fight it again and we're immune.
So, the adaptive immune system takes longer, it's slower, but it can mount a more specific immune response. That's typically a more robust immune response. But here's the thing and I always like to say if I'm giving a talk in person, I'll say all the good people in the room raise your left hand and all the bad people in the room raise your right hand. And most of us have both hands up. We can be sometimes good and sometimes bad. We have a little bit of that in us.
Well, when we think about what we're going to get into in a little bit, this idea of dysbiosis and the microbiome, it's all about balance. There are some organisms that are clearly pathogenic Ebola, bad actor, there's no good Ebola. But for most of what we're talking about, it's a matter of over or underrepresentation. Things get out of balance. And I liken it to a high school classroom. My daughter's a senior, graduating in a few weeks. And you want that diversity. You want some nerds, some athletes, some quiet ones, some loud ones, maybe there's even a bully or two in there, but it's the diversity of the classroom that creates the richness of the experience.
Now, if you have too many bullies or too many nerds, or too many athletes, then things are a little bit imbalanced. But it's actually that you wouldn't want a classroom full of good students of the super nerdy ones, you want a mix. And the same is true in society. You need that balance and that diversity. And so, what happens typically with dysbiosis is a lot of the healthy foundational species get killed off, too many antibiotics, acid-blocking drugs, or super sanitized environment. We'll get into all the causes in a little bit, but you have a reduction of the healthy sort of foundational species and then you start to get overproduction and colonization with some of the species that are normally there.
But now they're overrepresented and then pretty soon you get colonization and the place is sort of overrun with the athletes or the nerds or the bullies or whoever it is. And a yeast infection is a great example of that. We know that when we get a yeast infection, it's not really an infection. The yeast, the candida is there normally in our vaginas. But when we take/want too many antibiotics, we kill off the healthy lactobacillus species that are the predominant species in the vagina. And now the candida species are like "Woohoo, we got extra room, let's go out and multiply." And lo and behold, you have yeast overgrowth.
Now if you approach that by just saying, "I'm going to get me some nice statin and I'm going to kill off all this yucky candida." You will suppress the candida, but you'll still have all this extra room that was created by the lack of lactobacilli. And unless you really focus on regrowth and repopulation with a healthy lactobacillus, you're going to end up with recurrent yeast infections. And the same is true for bacterial vaginosis.
My OB-GYN colleagues find me really annoying. They're like, why don't you stick to the gut? Why are you trying to be a vagina doctor? But I'm really not trying to be a vagina doctor. But when we think about the vaginal microbiome, we have to apply the same principles that we use to the microbiome as a whole, which is balance. And so, what I see with my OB-GYN colleagues is a woman will come in with bacterial vaginosis, BV, the commonest indication for a woman to see her OB-GYN actually.
So, she will come in with typically, unlike a yeasty problem, where there's typically that thick, white, sort of cheesy looking discharge, it will be a thin, sometimes smells like fish, odor discharge, and sometimes there's itching. And she'll be diagnosed with BV, bacterial vaginosis, and she will be given an antibiotic.
So, the antibiotic, what's happening with BV is that instead of overgrowth of yeast, you have overgrowth of some of the species that are normally in the vagina, Prevotella, Gardnerella, but they're overrepresented. So, the ratio of lactobacillus to these other guys is off. And so, the Flagyl, the metronidazole that she's given will reduce the Prevotella, Gardnerella, but it will also reduce the lactobacillus.
So, everything will be fresh as a garden for a minute and then as soon as things start to come back, you'll come back again with the same imbalance BV. So, the key is to focus on repopulation with the missing species. And of course, that doesn't mean vaginal probiotics more than it means gut probiotics. It means judicious use of the antibiotic that killed them off in the first place. So, it's one of the things that I see over and over again, and I see women coming in on their fifth course of Metrogyl or whatever it is that I'm like, "This clearly isn't working." And it's the same thing I see with bacterial overgrowth in the gut. I see people coming in, taking these strong antibiotics, feeling better for a few weeks, and then it recurs because they're really not paying attention to what we're missing and sort of taking this scorched earth approach where we're just going to kill all the bacteria and hope for the best.
Cynthia Thurlow: Yeah, and I think it's important for people to understand this interrelationship between the oral microbiome, the gut microbiome, the vaginal microbiome. It's not as if they are closed-off entities, they are all interrelated, one begets the other. And much to your point, I can imagine as a gastroenterologist in terms of proximity, that would be a concern if someone's having recurrent vaginal imbalances that are creating symptoms and the antibiotics or therapies that are being used, they impact the complaints and the symptoms on an acute level. But on a chronic level, they're not addressing the root cause, core issue that is creating the imbalance or sustaining the imbalance that's perpetuating the symptoms.
Robynne Chutkan: That's exactly right. That's exactly what's happening.
Cynthia Thurlow: [laughs] Now, I think it's helpful to kind of another aspect of the gut microbiome and looking at the digestive system, things that we take for granted that are very important. I'm thinking about hydrochloric acid. We learn about it in biology. We go on to learn it at a deeper level and anatomy and physiology at an undergraduate or graduate level. Talk about hydrochloric acid and I'm hopeful that we can kind of bridge the understanding of hydrochloric acid and a certain medication or class of medications called proton pump inhibitors, which I was guilty of prescribing. Every single patient that came to the hospital got put on Protonix in cardiology. And they're designed to be short-term drugs. And what's happening is they are now being used judiciously for a very long period of time. And so, we have a whole generation of individuals that don't even recognize the net impact of not having enough hydrochloric acid, what that does in the body, and why that's so significant.
Robynne Chutkan: It's such an important topic, Cynthia. And I'll tell you, in the summer of 2020, there was a large population-based study that was published in one of RGI's journals. It was 53,000 people. And they asked a simple question, "Does being on a proton pump inhibitor increase your risk of COVID?"
Now, for me, as an integrative gastroenterologist, I knew the answer was yes because we know that when we block stomach acid. And these drugs, let me tell you, they are superb at what they do. They are A+ in terms of performance because they shut down that proton potassium ATPs that proton pump in the stomach. So, they create a medical condition called achlorhydria. Achlorhydria is a medical condition where you don't have stomach acid. And it's a pathological condition. And that's the state that these drugs are putting us into. So, the question asked, "Does not having stomach acid increase your risk of COVID?" And the reason I knew that was a yes is because we have seen for decades that people on these drugs, proton pump inhibitors, have higher risks of foodborne illnesses like salmonella, shigella, certain types of E coli, of Clostridium difficile.
So, any of these enteric infections, infections that affect the gut and SARS-CoV-2, of course, gets into our body through the gut a lot of the time, also through the lungs. So, any of these infections that enter through the gut, if you don't have stomach acid, you are much more susceptible. Why? Because stomach acid literally kills these pathogens. In the case of SARS-CoV-2, it unravels that viral protein, the spike proteins, and it dismantles all of that and makes it much less able to bind to those ACE2 receptors which are throughout the gut.
And so, when you don't have stomach acid, you've lost your body's main defense mechanism. Like, probably your most important defense, which is for stomach acid to denature the viral protein and render the virus inactive is gone. And so, what this study found was that people taking the drug, a proton pump inhibitor, as you said, Nexium, Prilosec, Protonix, Prevacid, there are a whole bunch of them on the market. They were twice as likely to test positive for COVID. And people taking these drugs twice a day as many people do, were three to four-fold more likely to test positive for COVID. And actually, Cynthia, I remember seeing this study, and it literally stopped me in my tracks. And I said to my husband, who is not a physician, he's a cybersecurity counterterrorism person. I said, "Honey, you know that, if you're on, like, Nexium, you're more likely to have COVID." And he looked at me, he was like, "Well, how would I know that?" Like, "What?" And I said, "Oh, you know, the stomach acid." And he's like, "Oh, okay, yeah." And then I asked a friend who's a dermatologist. She's a dermatologist and a pathologist, and she was also like, "Woo, I didn't know that."
And then, of course, when you explain it to people and then Cynthia, I asked some of my GI colleagues, and they were like "Ha?" And then I realized that this drug, I mean if you think you're prescribing a lot of it in cardiology, I mean, we're just stamping it on every patient who comes through the GI clinic or endoscopy unit. It is difficult to leave a gastroenterologist's office without a recommendation for a proton pump inhibitor.
So, the ones who are most recommending this were completely unaware of the risk. And this is when I said, "Okay, Public Health Service announcement." And I started out wanting to just write an editorial for HuffPo or something and I thought, "Okay, I'll write an editorial about the importance of stomach acid and how it confers this higher risk for viral infection." And then my wonderful book agent has worked with me with the other three books, said, "Well, maybe there's a book in here."
And then right on the heels of that study, another study came out showing that the composition of the gut microbiome was the most important predictor of outcome from SARS-CoV-2 more than age, comorbidities, etc. And then I was like, "Okay, people don't know this because people in my own medical community who are fantastic doctors, well educated, don't know. So, what are the chances that the average person knows? And that started on my journey to writing book number four, The Anti-Viral Gut.
But stomach acid, I have a slide that I use in talks where it shows proton pump inhibitors and it has all these arrows going around, and it shows increased risk of dementia, increased risk of kidney disease, increased risk of bone loss and fracture, increased risk of pulmonary complications, pneumonia, etc., increased risk of infection, all of these things. And so, you think, "Okay, how can one drug cause all these problems?" And the reason is because this drug is blocking, it is literally shutting down the most important ingredient in digestion, which is stomach acid.
Without stomach acid, it is impossible for you to properly digest and assimilate those nutrients. And of course, if you think back to the early part of our conversation, the GI tract is the engine, it's right in the middle. It's providing the nutrients for all the different organs. So, when you see, okay, the engine is compromised. There's no oil for the engine. You start to see how the brain is affected. The lungs, the kidneys, all the different organs are affected because the nutrient delivery to these other organs is compromised.
And so, somehow these pharmaceutical companies have convinced everyone, the physicians and everyone else, that we are overproducing stomach acid, which is just factually incorrect. Overproduction of stomach acid is a really rare condition called Zollinger-Ellison syndrome. Well, actually, I lie. I have seen cases of Zollinger-Ellison syndrome because when I was full-time at Georgetown, we had a joint appointment to the NIH. And all 3000 Zollinger-Ellison patients in the entire country are treated there because it's such a rare disease, somewhere between 1 in 10,000 and 1 in a million people.
But this is not a condition you'd really ever come across in the normal course of your practice. And so, it's a very rare condition of overproduction of stomach acid. But the other 300 million people in the country, it is not overproduction of stomach acid. It is that we're doing things that we shouldn't be doing. We're eating late at night, we're overfilling our stomachs, we're drinking too much alcohol, we're smoking, caffeine, all those things that cause that lower esophageal sphincter, that valve between the esophagus and the stomach to open inappropriately and let the acid come up.
But the acid level themselves are totally normal in 99.99999% of reflux. So, we've been sold a bill of goods by the pharmaceutical companies. We have been misled. And unfortunately, I think my GI colleagues have been complicit in that and convinced people that it's a good idea to create a disease state in their gut with these drugs that then lead to lots of other problems. So, we can talk about the increased risk of infections, not just viral, but bacterial.
We also know that stomach acid is an important ingredient for maintaining that gradient. As we go from the mouth down to the bottom of the colon, the amount of bacteria increases in our gut. And that's very intentional and that serves a very specific purpose. And so, now when we turn the stomach from an acidic hostile environment for bacteria into a nice friendly alkaline place for pathogens and bacteria to overgrow, we disrupt that balance.
So, really three big things. We dramatically interfere with digestion, we dramatically increase our risk of becoming infected, and we create imbalance, we create dysbiosis in the gut. So, I hope I've convinced everyone that acid blockers, other than for very specific indications like Cynthia referred to short term, you come in with a bleeding ulcer, things like that, or you've had a cardiac event and you have to be on some heavy-duty cardiac drugs that may cause some damage to the gut. Six to eight weeks, that's what we're talking about, what's recommended maybe even just two weeks. But as you said, people are on these drugs for years, for decades.
Cynthia Thurlow: Yeah. And it's interesting because I did both inpatient and clinical cardiology and the NP service in our cardiology group dealt with all the hospital follow-ups. And for anyone that's listening, cardiac patients generally go home on a milieu of medications and Protonix is always part of that. And so, I would always start the conversation and just say, not all these medications are necessary long term. Some people wanted to be on as little as possible. Others were completely immune. They're like, whatever you think I need to be on, I'm going to take. I'm not going to question anything.
The one other thing that I just want to tie in that you mentioned in the book that I think really will bring this home for people. PPIs or proton pump inhibitors are part of the top 10 most prescribed drugs in the world with annual sales of 14 billion dollars and 80% of people with prescriptions, it is unnecessary. So, if you're on this medication, don't stop it. Go have a conversation with your doctor, your healthcare practitioner. But understand that more often than not, these are designed to be used short term and not forever. Because of all the reasons that Dr. Chutkan just provided, this really impacts our ability to fight off pathogens, it impacts digestion, we can't absorb nutrients quite as effectively and that's quite significant.
Robynne Chutkan: Yeah. My GI practice has changed so much in the last decade and a half where I've gone from diagnosing more conventional GI conditions like colon cancer and gallstones and ulcers to things like dysbiosis and increased intestinal permeability, etc. But one of the things that is so dramatic is that I find myself in my practice spending so much time trying to undo the damage from these medications. So, I'm treating conditions that are in large part created by well-meaning medical colleagues who have people who are prescribing antibiotics unnecessarily or long-term, like putting people on antibiotics for acne.
They're putting people on long-term PPIs; they're putting people on NSAIDs. And so, it really is just trying to help people navigate when is a drug important versus not. And I 100% agree with you. Like, please don't stop or start any new medication based on what we're telling you here, which is for educational purposes. But please do have a pointed discussion with your healthcare provider, your prescriber, and ask some probing questions, like starting with. "Is this drug absolutely necessary?" Like, "What would happen if I weren't on this drug?" You'd be shocked at how often the answer is, "Oh, yeah, it's not necessary. Oh, nothing. You'll be fine. You don't have to take it." And you're like, "Okay, you've had me on this drug for 13 years. It's ruining my gut, and now you're telling me that, oh, it was icing on the cake. You don't really need it."
So, one of the things I do in the book, in The Anti-Viral Gut in the medication section and the plan is I go through each of these medications that are harmful to the gut starting with antibiotics. I go through proton pump inhibitors, nonsteroidal anti-inflammatory drugs, steroids, biologics, narcotics, all of them. And I recommend here are three or four really important questions to ask your doctor about these drugs.
And then here are some alternatives for how you can make them less damaging, whether it's an alternate day dosing, a decreased dose, a different version, a different medication altogether, a different therapeutic intervention that's not a drug because I really wanted people to have to not just be, like, the bearer of bad news, like, "Guess what? That NSAID is really ruining your gut. Got to just suck it up." But what can you do instead. Do you find, do you look back when you were doing hospital-based medicine and think, "What were we doing? I have those moments a lot."
Cynthia Thurlow: Oh, a lot, because as an example and I speak openly about this on the podcast, statin drugs, Zocor, Crestar, Lipitor, we prescribe routinely and all the time in cardiology. And I remember joking with a colleague and I always say, "Know better, do better." So, this is something that my colleague and I were talking about. And because of the population that we're seeing, we think statins need to be in the water supply. We actually said that. I mean, I cringe when I think about it. I did not say this in the context of being disrespectful. It seems like everyone needs them. And when both my parents were prescribed statins, I started to look a little more closely, because I noticed one of my parents cognitively, there was starting to be a noticeable shift in how sharp, my dad has always been this very smart person. And I started asking him, I said, I have this NIH researcher who's a patient who said, "I refuse to take statins." And that's what set me down that rabbit hole because she had pointed me in the direction of some research. And the more I understood about the way that they worked in the brain and what happens with low cholesterol levels, I mean, all these things that we kind of took for granted, we would increase the dose until we got to certain numbers on the lipid panel. And that's how we would determine whether or not it was efficacious or not.
And she really opened up my eyes and for which I'm forever grateful. But I noticed my mom started having a conversation with her providers about, are there alternatives? Can I be on less medicine? And she got off and was put on something else. And my dad was steadfastly like 80 g of Lipitor was what he was going to be on forever. And I've had conversations with his own provider about this and he wasn't willing to stop the drug or decrease it.
And so, I oftentimes reflect on things that we knew at the time that were standards of care that I now look at a little differently. I'm like, "Wow, we're looking at very myopically at one issue and not thinking about what the net impact was on taking this one drug, like whether it's myalgias or muscle achiness or elevated CKs, creatine kinase. I mean, all these things that were happening that I think back down, I'm like, "Gosh, instead of really focusing on lifestyle first, we're hitting patients hard with medicine to lower blood pressure, lower their blood sugar." I mean, all the things that were standards of care in that environment.
But yet I think about, "Wow, the net impact of not having those discussions, not having the time to be able to sit down and to have those long discussions about the things you're doing in your lifestyle that are impacting why you're on so much medication."
Robynne Chutkan: Or the knowledge. And as you said, that's still the standard of care. I had this discussion on Saturday with a friend. He's a urogynecologist and I'm good friends with he and his wife and we had a little double date playing squash and were having some dinner. After and chatting and he was insisting, "Oh, well, high cholesterol is just genetic. It's just genetic." Because I changed my diet and nothing happened. And I was like, "Well,