As a gastroenterologist, one of my major goals is to help people care for their gut better. That means talking more openly about our gut health in general.
It often amazes me how little we talk about something so intrinsic to our basic functioning. Recall, for example, how many times proper toothbrushing technique was drilled into our heads as children. But for reasons inexplicable to doctors like myself, when it comes to burping, farting, pooping or anything to do with our gut, we draw the line.
Perceived stigma about these topics can keep people from getting the answers and help they need to improve their overall health. For me, no question is off limits or too embarrassing.
So what should you know about your gut health? Here are six science-backed tips I’ve covered in previous columns.
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1. Don’t strain or linger on the toilet.
Sitting and pushing for prolonged periods of time - which tends to happen while scrolling through social media on the commode - can compromise the supportive tissue in our anal canals, potentially leading to symptomatic hemorrhoids. This is why I frequently remind my patients that they have one job, and one job only, when they take a seat.
Decades ago, doctors thought constipation and a low-fiber diet were the prime reasons people got symptomatic hemorrhoids. But studies over the years have not proved this consistently. And a high-fiber diet doesn’t clearly lower the risk of developing engorged hemorrhoids - though it is recommended as treatment.
Today, we think symptomatic hemorrhoids can be related to these factors - but it’s a more complex relationship. They are more likely a result of straining and hard stools (which can certainly occur with constipation, though not always). If your diet is rich in fiber but you’re still straining, talk to a gastroenterologist to help address why - there may be an issue with the pelvic floor muscles that could be improved with physical therapy.
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2. Know what’s ‘normal’ for you.
Most of the adults who come to my gastroenterology clinic have no idea what would be considered a "normal” bowel pattern. A general rule of thumb is that anywhere from three bowel movements per week to three per day is within the range of "normal.” Once-a-day bowel movement is great for many people. But the key to a healthy stool frequency is that however often it happens, it should be comfortable.
If you consistently have a bowel movement once a day, but to do so you have to strain significantly and take laxatives, then I’d say there may be a problem. If this sounds like you, speak with your doctor about ways to have easier bowel movements. Sometimes simple fixes such as increasing your water and fiber intake or boosting your exercise routine (which can stimulate your bowels) can make a big difference. On the other hand, if you have a bowel movement only every second or third day, but doing so is effortless without bloating, pain or undue straining, then that’s a healthy and "normal” pattern.
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3. Avoid taking drugs like ibuprofen.
Drugs like ibuprofen can damage our gut lining. That’s why you should avoid taking nonsteroidal anti-inflammatory drugs, or NSAIDs - such as ibuprofen, naproxen and aspirin - whenever possible. If you do need to take them, use the smallest dose for the shortest time feasible.
I don’t get too concerned if my patients take one or two doses every now and then. But through regular use, such as several times a month or more, NSAIDs are well-known to increase intestinal permeability.
Many people live with conditions like migraines, chronic back pain or bad period cramps and take NSAIDs on a regular basis to treat their symptoms. If that’s you, I’d advise you to have a chat with your physician and explore NSAID alternatives. Because NSAIDs do work well - and are cheap and over the counter - you may have never felt the need to discuss what else to try instead.
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4. Minimize your intake of sugary drinks and red meat.
Although we don’t have control over many aspects of why we develop cancer - including our genetics, our environment and our early-childhood exposures - there are a few areas where our own decisions can have a big impact.
I advise many of my patients to start by changing their diet. Eating a Mediterranean-style diet, which is rich in legumes, nuts, fruits and vegetables, can reduce the risk of colorectal cancer by around 18 percent. But so many people have been raised on a diet of highly processed, low-fiber meals, and their palates are accustomed to it. I have only rarely met patients who can go from zero to 100 when it comes to a dietary change.
That is why I recommend reducing your intake of foods that have been linked to colon cancer. That means avoiding sugar-sweetened beverages (such as sodas), red and processed meats, refined grains and alcohol whenever possible.
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5. Eat a fiber-rich diet.
The vast majority of us are not meeting the daily dietary fiber recommendations. But we should all be eating a fiber-rich diet. This time-tested recommendation remains one of the strongest-studied ways to promote and preserve a healthy microbiome and improve your overall health.
Eating a low-fiber diet leads to the loss of major categories of bacteria - and once certain groups are lost, they can be lost for good, even if you try to ramp up fiber intake later. So the time to act is now. The more diverse your diet, the more diverse your microbiome, and the healthier you are. So choose a variety of high-fiber plants, nuts and fermented foods to feed your microbiome the nutrient buffet it deserves.
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6. Think twice before cutting dairy entirely.
About two-thirds of the world’s population develops difficulties as the molecule that breaks down lactose in the small intestine, known as the lactase enzyme, switches off as we age. Without enough lactase, intact lactose cruises into the colon, where it gets fermented by our microbiome, leading to the production of gas and bloating.
Despite these symptoms, my advice as a gastroenterologist is: Don’t go cold turkey on dairy.
Studies have found that most people with lactose intolerance can tolerate at least 12-15 grams of lactose in one sitting - the equivalent of about one cup of milk. This is important because dairy products are some of our main sources of calcium and vitamin D. Furthermore, eating small amounts of lactose regularly can have a prebiotic effect by promoting the kinds of gut bacteria that can better metabolize lactose and improve our tolerance.
Try spreading out dairy intake over the course of the day and eat it with other foods, or choose low-lactose or lactose-free dairy products. Instead of plain, natural yogurt, try plain Greek yogurt, which has about half the lactose.
You can also try taking an oral lactase enzyme replacement such as Lactaid around 15 minutes before consuming higher-lactose-containing meals. These don’t work for everyone, and the data from randomized controlled trials is limited. However, it’s a simple and safe enough experiment to try for yourself.
Dr. Trisha Pasricha, MD, Boston, is the Ask a Doctor columnist for The Washington Post. She completed internal medicine residency at the Johns Hopkins Hospital and fellowships in gastroenterology and motility at Massachusetts General Hospital. She is an instructor in medicine at Harvard Medical School.
