#327 Constipation 101: Everything You Need to Know About Keeping Your Digestive System Working with a Gastroenterologist | Consultant Dr Angad Dhillon

Dr Rupy: Constipation is usually the butt of many jokes, pardon the pun, but whilst it might not be the most glamorous topic, it's one of the most common and overlooked health issues in the UK that could be reflective of a deeper issue. This is the deep dive episode into constipation that many of you have been asking for with consultant gastroenterologist, Dr Angad Dillon.

Dr Rupy: Hi, I'm Dr Rupy. I'm a medical doctor and nutritionist. And when I suffered a heart condition years ago, I was able to reverse it with diet and lifestyle. This opened up my eyes to the world of food as medicine to improve our health. On this podcast, I discuss ways in which you can use nutrition and lifestyle to improve your own wellbeing every day. I speak with expert guests and we lean into the science, but whilst making it as practical and as easiest possible so you can take steps to change your life today. Welcome to the Doctor's Kitchen podcast.

Dr Rupy: Constipation affects one in seven adults and up to one in three children experience it, and it's responsible for thousands of hospital admissions every year. So this week, I'm joined by Dr Angad Dillon. He's a consultant gastroenterologist and accredited bowel cancer screening endoscopist at Lewisham and Greenwich NHS Trust, with advanced training from St Mark's Hospital, one of the world's leading centres for intestinal disorders. Dr Dillon also specialises in complex endoscopy, bowel health and digestive wellbeing, and he also happens to be my best friend from medical school, who I've literally known for over two decades. We talk about lesser known constipation strategies, what functional constipation means and functional gut disorders in general, how it can be related to other medical issues and what you should be optimising before you reach for a laxative or any other supplements and medications. We're going to explore what normal actually means, whether the Bristol stool chart that I'm going to be showing to him on YouTube is actually useful or not. How to approach constipation with a dietary approach, why pooping posture and breathing and stress matter for your health. The links between sleep, circadian rhythm and digestion, and red flags that mean it's time to speak to your doctor. You can find Dr Dillon's research on our podcast show notes and a number of different studies that we've linked to in the show notes as well.

Dr Rupy: Angad, look, you see patients all day long in both private and NHS, right? Constipation is something that must come up quite a bit. So why don't we talk about what constipation is? Actually, before we do that, why don't we talk about some of the commonest things that you see as a gastro consultant?

Dr Angad Dillon: Commonest things as a gastro, constipation is right up there. I mean, constipation, I would say easily in the top five. I think the bread and butter for most gastroenterologists is going to be irritable bowel syndrome. And part of irritable bowel syndrome is irritable bowel syndrome with constipation predominance.

Dr Rupy: Got you.

Dr Angad Dillon: I would say the more common is with diarrhoea, constipation and diarrhoea, but you get mixed. It's a mixed bag. You can get patients who experience predominantly constipation, predominantly diarrhoea, and vice versa. It kind of, it's quite erratic. You also get a bloating predominant type. Really big issue. I see a lot of that. But yeah, IBS is right up there. So, I mean, the other things, I mean, you're talking thinking of things like inflammatory bowel disease, ulcerative colitis, Crohn's disease. Another big thing we see a lot of, fatty liver disease. Numbers are going up and up and up and up. Fatty liver, inflammatory bowel disease, IBS. Bowel cancer is the other big one.

Dr Rupy: Yeah. And when, so I think it's really important to contextualise when we are talking about constipation, it could be part of a constellation of other things going on with different root causes, right?

Dr Angad Dillon: Absolutely. Nobody will ever come into clinic and say, doctor, I've got constipation. It's never an isolated thing. And how do you even define constipation, right? It's a subjective thing. I mean, it's usually the case of patients will have complaints of abdominal pain, straining, bloating, they're finding that their frequency is changing, and you will tease out in the history and come to a picture of someone who is suffering from constipation. I don't think, exactly as you said, it's not something that is just an isolated issue. It's usually part of a bigger picture of something that's going on. And our job is to kind of just tease out what exactly are the factors which, yeah, we can absolutely talk about.

Dr Rupy: Yeah, yeah. Let's talk about constipation from a wider perspective. Like, how big a problem is it? You've already said that it's top five.

Dr Angad Dillon: Top three, top five, absolutely.

Dr Rupy: Yeah, yeah. So in terms of like the grander scale, if we're looking at the UK, like how many people would, how many adults are constipated?

Dr Angad Dillon: It's very hard to say because again, firstly, how are you going to define it? I mean, if you want strict definitions, you've got what's called the Rome IV criteria. So that's, that's looking at kind of functional disorders. They they have set definitions for things like dyspepsia, IBS. Functional constipation, you'd say somebody who is not opening their, is opening their bowels less than three times per week. And that's been going on for more than, I think, three months. But then there's it's not just a case of frequency, it's also are they straining more than a quarter of the times they're going? Are they, is the stool very hard? I can see you've got the Bristol stool chart there, so we're going to have a look at that. And so if you use those strict definitions, I'm sure it's it's going to be a bit lower, but I would say a big percentage of the population suffer, maybe something like one in seven, one in 10. So yeah, it's and I think it is a big burden on the NHS. And it's it's difficult. It's it's a big problem in terms of people's quality of life, can cause a lot of stress, a lot of uncomfortable abdominal issues. So a big burden on the NHS. And sometimes it's also quite, it's also masked a lot. Sometimes patients can have constipation without knowing they're constipated. I'm sure you must have seen back in the days when you were in A&E, patients presenting with flares of their inflammatory bowel disease. So, so usually people think about inflammatory bowel disease, diarrhoea. So they'd come in thinking they've got diarrhoea. And they're thinking they've got an inflammatory bowel disease flare. You do an abdominal X-ray and you see the whole proximal part of the colon is full of stool. Totally, yeah, yeah. And you're thinking, how on earth can I be constipated when I'm going to the toilet three, four times a day? And that's that's what's called um, constipation with overflow diarrhoea. So the body's natural way of protecting that inflamed bit of bowel. So say you've got an inflamed rectum, you've got proctitis. The body is not going to, is going to try and hold back and protect that area. So you've got this kind of build up of stool, but the inflamed area is causing mucus and secretion, so you're still getting diarrhoea. So that's so it's not always a straight case of it's obvious that someone's got constipation.

Dr Rupy: This is this might be this is going to sound so counterintuitive to people who have had that sort of experience where they're like, well, no, doctor, I can't be constipated. I'm literally going all the time.

Dr Angad Dillon: It was a shock to me as a junior doctor. I remember the first time someone told me this patient's constipated. I was like, how are they constipated? They've got a flare of their inflammatory bowel disease. It's not possible. But you see, you show the patient and you see yourself the X-ray and it's just the right colon is full of full of stool. And it's not that, it's not just that situation. You could be doing scans for a number of causes. You're you're investigating something else. Someone happens to have a CT scan. Invariably in the report it's going to say there's a degree of what's called fecal loading. So there is a backup of stool. That doesn't necessarily mean the patient's constipated, but it can suggest that they are having a degree of build up without even knowing it.

Dr Rupy: So this sort of speaks to, people might be surprised that I'm doing a full podcast episode on constipation, but I think

Dr Angad Dillon: Mate, you surprised me. How are we going to tell, how are we going to be talking for two hours about constipation? The first time you got me on my podcast of all things to talk about. The most glamorous thing.

Dr Rupy: But it's so, it's so common. It's really misunderstood. It's the prevalence like you said, like one in seven, and I think even in kids as well, it's even more prevalent. It's like one in three, which is and it's a crazy amount of burden on the NHS. So the more we can sort of tackle it in a preventative way, the better. And the more educated people are about what constipation looks and feels like, the better as well. Because I think it's very individual. So you were saying like for for what, so is there a definition of what is normal? And what could be normal? What is the sort of the the degree of of normality in terms of stool frequency?

Dr Angad Dillon: So I can only speak from my experience, right? I can't give you official epidemiological stats. For me, a man usually will go once a day. A female will usually go once a day or once every other day. So a slight predominance towards a little bit of constipation in females. That I would say is broadly speaking the normal. You can have patients opening their bowels um, three times a week and that is normal for them. If they've been, if that's how their habits been for a long time, I wouldn't actually worry about that. It's more the change you're looking for. So has someone's bowel habit changed? Have they gone from going once a day to now going once every two days? So that's not technically constipation, but it's a significant change there. Or it's it's how it's the changing pattern that I look at and I'm looking for.

Dr Rupy: Okay. So there's a there's a wide variety in terms of like frequency and what is normal and what we're looking for is the change, the velocity of change. What about the actual, and we're going to go a bit deeper into the stool itself here. What about the actual stool, the process of passing and things like colour, texture, all that kind of stuff?

Dr Angad Dillon: Yeah, that's a good question. Um, in in clinical practice, I think these things are important, but it is highly variable. I mean, it completely depends on what you've, your level of hydration, what you've had to eat. Um, so I don't like to get too caught up in what the shape of the stool is, what the how soft it is. Yes, that's important. Um, but again, it's more how it's evolved, how has it changed? Um, we were talking about the Rome IV criteria. So so part of that, yes, you will meet the criteria if you are passing Bristol stool chart one or two, which is basically like solid rocks or pebbles. So we've got it here. So I don't know if people can see this.

Dr Rupy: Yeah, we'll we'll put it up on YouTube, but we can describe it to the audio listeners as well.

Dr Angad Dillon: So yeah, type one, separate hard lumps, nut like it says here, hard to pass. Type two, sausage shaped but lumpy. So from my point of view, type three or four would be your kind of normal, what you'd expect. And I think in Rome IV, they do say if you're if you've got predominantly more than 25% of the time passing type one or two, that is a constipation picture. But again, you'll never see me pull out this chart in a clinic and ask a patient what they're doing. It's really? No, I wouldn't. I think this is more more a tool for when you're doing studies and you're trying to put people into trials and have strict criteria and classifications. This is not a tool I commonly would use in when I'm sitting speaking to a patient. I'm talking about the trends, what's changed, how does it feel? Are you straining on the toilet? Is it painful when you're passing a motion? These are the kind of things that I'm more interested in. How the patient's experience of it is.

Dr Rupy: That's really reassuring because I think a lot of people will look at this stool chart and be like, oh my god, I've got type one. Exactly, yeah, like, oh, my my my stool always look like type one and it should be three or four and if it's not looking like three or four, there's something wrong. I've got to have a gut test, I've got to change my diet, I've got to start drinking more, like, you know. And those are all those things might be true, but what is normal for that individual doesn't necessarily mean that it's always going to be a particular number on the stool chart.

Dr Angad Dillon: Absolutely. And I'm sure you've experienced it yourself. I mean, just going abroad, going to a different country, having a different whole different type of cuisine, your stools are going to be absolutely different. I mean, nobody has the same consistent stool pattern. It's very variable.

Dr Rupy: Yeah, okay. So, the frequency is very individual. We're looking for change. Um, are there any other symptoms of constipation? Like we talked about one where it could be um, it could feel like a flare or it could be a flare of IBD and actually you're constipated. Are there any other symptoms that you see that you hear of about in a in a patient history like, ah, that could be a sign of constipation that might be unfamiliar or unusual for for the listener?

Dr Angad Dillon: Yeah, yes, there are. So I think the big one would be bloating. Bloating, this sensation of fullness. I've had patients say to me, look, doctor, I I I I feel at times in the evenings, I look five months pregnant. And and um, very often if you delve into the history, it's not obviously apparent to the patient that they're constipated. Um, but but but they they have if you really go into it, yes, they they're over time there has been a build up. Um, so so bloating would be right up there. Abdominal pain would be there. Uh, there's an important symptom called tenesmus, a sensation of incomplete evacuation. So you're finding you're straining on the toilet and you're not quite able to have a full complete motion and you're spending long time on the toilet. That is in itself not a red flag, but if that has been a persistent symptom daily, then that is a bit of a red flag and that does warrant some more investigations, absolutely. Um, if it's kind of an intermittent type of symptom, you sometimes get it, you sometimes don't, uh, that is could be a sign of constipation or the stool getting a bit hard and blocked up.

Dr Rupy: Got you. What about um, like a feeling of sickness or nausea?

Dr Angad Dillon: Nausea, yeah, and nausea I would worry. That that would be you're thinking now about something called subacute obstruction. So sometimes you can get issues in the bowel where you've got narrowing, blockage, strictures. That's pretty serious. So that I would hope most people would seek some medical help and it would be pretty apparent because your tummy would swell up, you'd start, you'd stop passing wind, um, you would feel sick and nauseous, you might have what's called feculent vomiting. Um, and that's a pretty serious thing. So, so yeah, that that that you wouldn't see as commonly. That those kind of patients you'd usually present to A&E.

Dr Rupy: Yeah, yeah. I mean, we'll talk a little bit about some of the extremes of constipation and the causes of those extremes that are probably becoming a bit more common given the low fiber diets and the western diet, like, you know, diverticular disease and all the rest of it. Um, but I think it's good to to get like a general understanding of what the symptoms could be that are related to constipation that people might not even realize. Because I don't think people are particularly, this is from my anecdotal experience, but also just speaking to folks, we're not really attuned to our bowel habits. I don't think we have the culture of like, okay, I didn't go today or it's been a couple of days or, you know, unless you're actually getting another symptom associated with it.

Dr Angad Dillon: Yeah. But my experience is that, I mean, a lot of people are lucky, they do have, they are like clockwork. So a lot of patients will say to me, look, I I I've always woken up in the morning, have my cup of coffee and I'm opening my bowels and it's like clockwork. So for that kind of patient, I'm more concerned if there's a change. But absolutely, in the way our lives are at the moment and not having regular eating patterns, not having regular sleep patterns, variability in bowel habit is inevitable. I mean, I remember, and I'm sure you do as well, when we were on call as medics doing night shifts, bowel patterns would be all over the place. I mean, you would not have a regular motion on clockwork when your circadian rhythms are off and your diet is changing. Um, so yeah, I mean, I often think like, look, what what is the underlying, why is, why do human beings get constipated? And if you think about it, we've got the colon is like what, 1.5 to 2 meters long. And the colon is the large intestine. That's the large intestine. And people can have surgery to remove their colon and they're pretty fine. I mean, they have normal lives. So why do we have this long colon? Like what's the purpose? And my personal feeling is, look, when when human beings learned how to make fire and cook their food, you've now turned a process that's very laborious, having to digest, break down food, absorb nutrients. You've now, you're now cooking. So you're making those nutrients readily available. So you look in the animal world, omnivores, animals like cows, they have huge stomachs, long, long GI tracts. Um, and so evil, it's it's like one of those evolutionary legacies, right? We've got this super long colon, um, I'm not saying that you don't need your colon. It serves a purpose. It's host to trillions of different microbes and um, but but it it's kind of not a design flaw, but evolution has this way of being amazing at like natural selection, developing these complex structures and organs and the eye, but it's got a very bad memory. So the original blueprint of of how we were, it can't go back and then shorten the bowel, right? So we're left with this legacy of having this long colon and of course you are going to get build up, you are going to get um, changes in how you open your bowels.

Dr Rupy: Totally, yeah, especially when your diet has rapidly changed over the last 100 years. We haven't adapted to this this modern environment, so.

Dr Angad Dillon: Exactly. Have you ever heard, there's a story about the recurrent laryngeal nerve. Do you know about that one?

Dr Rupy: So that is, oh, I've heard, yeah, yeah, because it it loops back on itself, right?

Dr Angad Dillon: Yeah, so it's it's completely counterintuitive. Why would you have this nerve that leaves the brain, travels with the vagus nerve all the way down to the, I think it's the aortic, the aortic arch, and it loops back up to innervate the throat. It's like, why not just go straight there? And then it's even more pronounced in like animals like giraffes, right? Who have got these super long necks. And you think, what's the design there? And it's um, it's just a legacy of evolution and natural selection. When that nerve first kind of evolved, we didn't have necks. We were probably fish. And it was it was innervating like gills. And then as evolution takes hold, it has to kind of rewire back up, you know?

Dr Rupy: Yeah, yeah, yeah. Yeah. It's amazing. I mean, like, there's the same thing with the appendix, right? Like, do we have we figured out why we have an appendix or there are theories or?

Dr Angad Dillon: It's a good question. I remember in med school, everyone was like, oh, it's a vestigial organ, it's a remnant, it's not needed. There's a lot of interesting research and a lot of people looking at the role in the microbiome. So I'm not saying that the colon is a redundant thing. Absolutely not. Um, but it's just um, it it's a legacy. It's not optimally designed. Um, the appendix, I don't think we actually have got, we don't know exactly what it's doing, but absolutely it's got an important role um, in in the gut microbiome as a as a kind of store of bugs. Um, yeah.

Dr Rupy: Well, there's this idea of um, stool banking, right? So when you go in for an operation or you know that you're going to have a load of antibiotics as a result of an infection somewhere else in the body, there's this concept that, okay, maybe you should bank some of your stool, um, and reintroduce that after you've had the antibiotics to repopulate your microbiome. And it almost feels as if the appendix could be a little reservoir for when you did have these instances during evolution where you just, you know, had diarrhoea or you ate something dodgy or you came into contact with a pathogen, you expelled all of it through your gut and then you still had some backup microbes to repopulate the empty colon.

Dr Angad Dillon: But that's pretty intense though, if someone's having antibiotics to store some of their stool. I mean, seems a little bit overkill.

Dr Rupy: It might be overkill, but I think the thinking is you're not um, removing all of the beneficial microbes and allowing the pathogenic microbes to repopulate, which tend to be quicker um, growing than your the other microbes.

Dr Angad Dillon: Maybe in patients who are on recurrent courses of antibiotics.

Dr Rupy: That's the, yeah, not not like an amoxicillin course. Yeah, yeah, yeah. I think it's more like IV or if you're, you know, in an ITU or something that's going to require a long course of antibiotics, maybe even chemo patients, so, yeah. No, it's really interesting looking at the sort of the body through an evolutionary lens.

Dr Angad Dillon: It is. I find it fascinating. It really is, yeah. There's so I'm sure there's so many other examples that are not coming to mind that you could point out that this is not flaws, they're not flaws. I think we're beautifully designed, but they are just um, little uh, interesting quirks of our human body.

Dr Rupy: Yeah, yeah. Okay, cool. So, um, you mentioned a couple of things that I just want to clarify. Functional constipation. What do we mean by functional constipation?

Dr Angad Dillon: The gut is not doing its function. So there's not disease there. Uh, you haven't got an autoimmune condition that's driving inflammation in the bowel. You haven't got a tumor sat there, you haven't got an abnormal polyp or a stricture. The gut is not functioning as it's supposed to function.

Dr Rupy: And what would be the causes of that or the the thinking behind why the gut isn't doing its job if there's nothing anatomically wrong or physically wrong?

Dr Angad Dillon: That is a super deep question and it doesn't have a simple answer. A lot of people want there to be a simple answer and a simple cure. It is multifactorial, right? So there are so many different things you could, you could talk about here. I mean, how would we break it up? So, so in function, when you're talking about functional constipation, I suppose the way I would break it up is you've got slow transit, so idiopathic slow transit constipation, the bowel is just slow to move things along. Um, then I would say there is functional outlet obstruction. So the bowel is working, things are moving along, but for some reason there is a hold up right down at the bottom. And then, uh, the third one would be, um, irritable bowel syndrome, which to be honest with you, is kind of just a bit of the other two, but with the added issue of abdominal pain. The classic feature of irritable bowel syndrome is pain, right? Abdominal pain. Um, those are the function, that's the functional side. Okay. Let's not forget about the medical side, because by training, that's really what I'm looking for. So your classic things, hypothyroidism, um, hyperkalemia, uh, calcemia. Calcemia, yeah. Um, diabetes, uh, Parkinson's, neurological conditions, inflammatory bowel disease, bowel cancer. So that's the medical side. So my job, obviously, would be to from the history, from investigations, make sure we've excluded those things. Once we've excluded those things, then yes, we're looking at the three functional things. Slow transit, functional outlet, and IBS-C.

Dr Rupy: Ballpark figure, how, what percentage are we talking about with functional constipation? Like, how many people are actually having functional constipation, i.e. constipation issues without a clear medical cause?

Dr Angad Dillon: I would say the majority. I wouldn't be able to give you a number, but I would say the majority. Okay. Um, in my experience, I find that if you look at patients on multiple medications, so polypharmacy, and I think they've done studies on this as well, actually. If you're if you're taking more than six medications, your likelihood of getting constipated is going up and up and up. Uh, so that just goes to show kind of medical conditions, drugs cause constipation. So that there is a big proportion there, but um, I would say the vast kind of patients I see in clinic are it's going to be a degree of functional constipation. It would be the majority. Yeah. Yeah.

Dr Rupy: I don't think people have really put together the um, medical reasons as to why they could be um, constipated. So type two diabetes and constipation, I don't think people put those two together. Neurological conditions, Parkinson's, I don't think they've put those two together. Thyroid disease.

Dr Angad Dillon: With the medical community, absolutely. Obviously, yeah, but from a patient's point of view. Yeah, yeah, yeah. Parkinson's is a big one. Patients with Parkinson's really do, they suffer from um, um, constipation. But it's not so not just the neurodegenerative condition, it's the it's all the medications they're on as well. The big one I haven't mentioned is opiates. So many opiates uh, in use nowadays that it there is a something called a narcotic bowel syndrome. So opiates really have a powerful impact on gut motility. Um, and I'm sure, I don't know if you've ever used a codeine or something like that. You will be bunged up the next day. Absolutely.

Dr Rupy: Yeah, yeah, yeah. And the thing is like a lot of these medications you can buy over the counter. Codeine, can you still buy the low strength over the counter?

Dr Angad Dillon: I think you can, yeah.

Dr Rupy: So, I mean, that in itself is is quite worrying the fact that you can get codeine without a prescription.

Dr Angad Dillon: And especially if, like you said, if patients aren't aware about that, they're taking codeine, they're not making additional changes. They're not making sure they're keeping hydrated when they're on it. They're making sure they're getting increasing their fiber intake or whatever other measures they need to do to stop themselves getting constipated.

Dr Rupy: Yeah, yeah. Um, and you mentioned a big one, uh, bowel cancer. Um, common symptom for early stage?

Dr Angad Dillon: Actually, actually, no. In my experience, when you're investigating people for constipation, it it's not usually bowel cancer, actually, thankfully. Bowel cancer can present very insidiously. You can have no symptoms, which is we can talk about this later, why we have bowel cancer screening in this country. But it's usually more loose loosening of the stool and increase in frequency and obviously blood, seeing blood in the stool. Constipation can, but less commonly. In my experience, when you're investigating a patient for constipation and they end up having a colonoscopy, invariably it's normal. If anything, it's normal, it's actually a difficult colonoscopy because by nature of the fact they're constipated, the bowel prep isn't usually great. They usually have long redundant loops of bowel and it's actually quite a challenging colonoscopy to complete, but it's inevitably normal.

Dr Rupy: Can you just explain to folks what bowel prep is?

Dr Angad Dillon: Bowel prep is um, the the the stuff you drink uh, to um, clear out and uh, clear out the bowel so that when you perform a colonoscopy, uh, you can get good views of the lining of the bowel. And and really what you're trying to do is is assess all the different folds and inner lining of the bowel, looking for abnormalities, uh, ulcers, inflammation, uh, polyps. Um, so so to get good visualization, the bowel needs to be cleared out. So you're usually prescribed something called PEG, uh, polyethylene glycol, um, and some other kind of um, minerals and electrolytes are added in, ascorbic acid, and that is going to clear out your bowel, um, as long as it's important you're obviously drinking lots of water with it and you're fasted. Um, and then that's what you do in preparation for a colonoscopy.

Dr Rupy: Cool. Okay. So we've talked about um, some of the medical causes of constipation, of which there are many, functional reasons for constipation. This is the Doctor's Kitchen. We want to talk about diet and lifestyle reasons and some of the other lesser known issues that might be causing constipation that are psychological in origin. And actually, we'll talk about the wider sort of psychological uh, reasons why people might be coming to see you with with with actual bowel issues. So diet and lifestyle, what what is going wrong and and what are the the key reasons as to why that could be leading to constipation?

Dr Angad Dillon: It purely sticking on diet.

Dr Rupy: Yeah.

Dr Angad Dillon: I would say, I mean, the big one is obviously fiber. That's historically is you're constipated, get more fiber in your diet. You could probably tell me this. What what's the um, what's the recommended amount of fiber we should be these days? Is it 30 grams?

Dr Rupy: So it's 30 grams is the the general sort of uh, theme of like how much we should be aiming for every day. I think that's honestly the bare minimum of fiber.

Dr Angad Dillon: Are people getting 30 grams of fiber?

Dr Rupy: They're not. No, no, no. The majority, the majority of people are not getting 30 grams of fiber in their diet, which is why there's a big push, particularly online from nutritionists and even myself, to try and increase people's fiber. I think it's more of a function of the processing of food and how reliant we've become on pre-packaged foods rather than cooking from scratch. Um, and I don't think that should be at the expense of like things like protein that are very important, particularly once you reach a certain age and you tend not to consume enough, your appetite goes down, you have multiple morbidities. But fiber is a really, really big concern. Um, and it's not just so much about fiber in and of itself. As you know, there are so many different types of fiber out there. And the best sort of rule of thumb is to try and get as much variety as possible.

Dr Angad Dillon: Exactly what I tell patients. It's diversity, right?

Dr Rupy: Yeah, exactly. Yeah.

Dr Angad Dillon: So I think that's where patients might be lacking who are getting simple cases of constipation. They're not getting that diversity of fiber that uh, 20 or 30 grams per day that they need. Um, uh, and like you said, yeah, it's it's not, I think it should you should also think in terms of diversity of fiber, but also there are specific recommendations you can make. So the difference between soluble and insoluble fiber. So soluble fiber is the stuff that is water soluble, right? Um, and so these are going to, when you ingest them, they're going to draw water in and they are going to form like this kind of soft gel-like substance to help things moving, um, and to help keep the healthy colonic transit. Um, so in patients who have got constipation, that's what you really want to be boosting the soluble fiber. Insoluble fiber, I don't know if you agree or disagree. I think it's actually important. It's got a bad rap in that the insoluble fiber is the stuff that is not drawing in water. So that's going to bulk up the stool, but for a lot of people, it's going to cause maybe more pain, more straining, more bloating, uh, because you're not getting that soft gel-like um, uh, kind of mucilage layer. Exactly. Um, but that's where a lot of nutrients are. I mean, insoluble, insoluble fiber, so with thinking of what things like whole grains, bran, and if I'm not mistaken, that's where a lot of your, I mean, you will know this better than I do, that's where you're going to get a lot of the phytonutrients, the minerals, the vitamins. Um, so, so, so just bringing this back to the patient who's got constipation, you want to ensure they've got that diversity of different types of fiber in their diet. You you've said this beautifully on the podcast. So lots of different colors on the plate, lots of different varieties, plant fibers, I mean, that's the place where you're going to get them, right? Um, but then when you find your bowel habits are reducing in frequency to add in more soluble types of fiber.

Dr Rupy: Yeah, yeah. I mean, when we were at medical school, the way it was described to us was roughage, right? It was just like, you know, it's stool bulking, it's going to push things through. And I think we've moved on in our understanding of how important these materials are to the microbiota and shaping that microbiota to be more in line with um, an anti-inflammatory picture in your bowel, uh, supporting those microbes to support the mucin layer in your gut, bolstering up that gut barrier defense, um, and even doing things, you know, beyond the gut, you know, reducing your blood sugars and improving your your mental health and all the rest of it. So I think it's about getting that balance between soluble and insoluble. And even within that, there are so many different subtypes as well and different types of of of fibers. So I think the the idea is to try and get those soluble fibers, you know, get it from fruits and vegetables, but also supplementing when possible, when I think it's almost like later on you want to go for the the insoluble fibers and that sort of, you know, the background roughage, um, and titrate those up um, uh, before, you know, um, after, sorry, doing the soluble fibers. That that's the way I think about it. And hydration is another big thing as well.

Dr Angad Dillon: Big one. Because if you are increasing your fiber, you need the water to to to help draw that into the bowel. So yeah, I mean, I think the guidelines are what, 1.5 to 2 liters per day, eight cups of water a day. And I think I see that a lot. I mean, young people, busy, on their feet, not drinking enough water. So absolutely. Um,

Dr Rupy: I mean, do you get people to measure how much water? I mean, this might be, you know, because you you're lucky to work with dietitians in your private practice, right? So you get them to sort of assess hydration status and like what they're eating and all the rest of it. But are there sort of formulas that you use to to increase hydration or do you just generally go for like a 1.5 to 2 liters?

Dr Angad Dillon: What do you mean by formulas?

Dr Rupy: So according to body weight, um, their their, yeah, their their size, their mass.

Dr Angad Dillon: No, I don't. But one thing, uh, recently about we've I've been doing with water is um, stressing the high mineral content of the water. Because I think there is some evidence that high, so you're, you know, your bottled waters with high levels of magnesium. That is going to, that I think the studies and the meta-analysis have shown that that is beneficial over just your simple tap water. But but no, no, not I haven't really, my my general advice is, you know, I keep one of those bottles which has how much you should be drinking throughout the day. That's usually my advice.

Dr Rupy: I spoke about this with um, uh, a couple of urologists a couple of years ago on the podcast. And even they were like, look, uh, eight glasses a day is pretty general. Um, people should be drinking more water. There is a sweet spot between like uh, 1.5 and 2.5 liters, but it really goes on the color of your urine. So you want to be going for like a light straw colored urine.

Dr Angad Dillon: And how active they are, where they live, what the temperature's like. All these kind of things.

Dr Rupy: There is a trend to getting more electrolytes in your water. I personally take electrolytes when I'm training on days that I know that I'm going to be sweating quite a bit. But as a general rule of thumb, I tend not to have electrolytes every single day. I don't know what your thoughts on that are or whether you think it would help.

Dr Angad Dillon: Creatine, does creatine, is that dehydrating?

Dr Rupy: It can be dehydrating because it draws water into your muscles. I'm not too sure the extent of which, but it might also be reliant on the dose of your creatine as well. Because I remember I said to you that I'm taking 15 grams of creatine.

Dr Angad Dillon: 15 grams of creatine. But that is the hot topic at the moment, isn't it? That's on social media, everyone's like, oh, creatine is the wonder thing.

Dr Rupy: Yeah, yeah, yeah. Creatine is because of the links with brain protection.

Dr Angad Dillon: Brain health, yeah, yeah. So so so so if you're drawing all this water into your muscles, surely that is going to have a degree of strain on the kidney, no, or?

Dr Rupy: No, not necessarily, because it shouldn't be dehydrating you to the point where you're you're you're losing that much water. Um, secondly, I wouldn't advise people go straight to 15 or 20 grams of creatine straight off. I would build it up slowly. So I was taking 5 grams. I measured my uh, my bloods, my kidney function is completely normal and I don't have any pre-existing history of any issues. What I what I would say is, um, you want to be cognizant of the potential GI side effects as a result of the the the um, the water changes. But I take it because that high amount because you want to saturate your muscles demand for creatine first, and then there may be some extra benefits to your brain. That's the sort of very early stage, I would say. There isn't nowhere near as much evidence around those potential benefits of creatine. But someone, like we we've got kids the same age, right? One year olds. We're both sleep deprived. Are there if there are any potential benefits to our brains, I I would be taking it all day long. Yeah. Like I I I'm willing to take that bet that creatine is going to be helping me and my sleep deprivation, which is why I take it. And I'm not experiencing any GI side effects either.

Dr Angad Dillon: So I mean, it's one of the safest, it's one of the safest things out there, right? Yeah, yeah, yeah. Um, but do we know it's safe at those doses?

Dr Rupy: I would say so, yeah. I mean, looking at the uh, the research and keeping an eye on my own bloods, like I I don't think there's any evidence to suggest that it's unsafe at those levels. Particularly as they have been taken at much higher levels by the bodybuilding community and, you know, athletes and all the rest of it. So.

Dr Angad Dillon: Well, bringing it back to people with constipation, um, another trendy supplement is magnesium.

Dr Rupy: Yes. Yeah, yeah.

Dr Angad Dillon: A lot of people talk about magnesium and sleep.

Dr Rupy: Yes. What do you think about magnesium?

Dr Angad Dillon: Three and eight. Yeah, three and eight, glycinate. I tried it. I mean, I didn't notice any difference. We both track our sleep. I know you want to get one of these things. I didn't really notice much difference with magnesium, but I think people are different, they respond differently.

Dr Rupy: Is that from a sleep point of view or a constipation point of view?

Dr Angad Dillon: This is what I'm coming to. So recent meta-analysis, I think by the uh, British um, dietetic association, they have shown really good impacts on constipation with magnesium oxide supplementation. Very safe and it has got sustained uh, results with improving constipation. So yeah, I mean, if you are suffering from constipation, I think that would be quite a supplement, a sensible uh, supplement to try, which is evidence-based.

Dr Rupy: Yeah, yeah, yeah. I want to talk a little bit about our lifestyle as well, because you mentioned earlier about um, how when we were doing night, you don't do night still, do you?

Dr Angad Dillon: Thank God, I did my last night shift about three years ago.

Dr Rupy: Oh mate, amazing. Um, so yeah, I don't do nights anymore, obviously. Uh, I gave that up about three years ago, but when I was doing nights or even just shift work, actually, when I was like finishing at 11:30, 12, 12 a.m., um, my gut would be all over the place. So the impact on circadian rhythm shifts, I'm assuming there is a mechanism behind how that might be changing your bowel habit, whether that's alternating constipation or diarrhoea.

Dr Angad Dillon: Well, the gut has its own circadian rhythm. It's all linked. I mean, um, if you, so this is another uh, um, another, another thing in the armamentarium for managing constipation when I'm advising patients, optimizing their sleep. If you can get into a regular sleep pattern, you are going to have consistently regular circadian rhythms and you're you are going to be more regular with opening your bowels. Um, uh, and that it's not, it's not just the circadian rhythm. I mean, during sleep is where the body is getting into a lot of homeostasis, it's balancing different hormones, melatonin production, um, I think there've been studies looking at sleep and when you uh, are waking up the next day, the levels of um, hunger hormones, ghrelin, leptin, all these things. Uh, so these all have a big impact on eating behaviors, um, and the body's kind of natural clock, natural rhythms. So absolutely, I think sleep is one of those things that's so um, under underrated and it's it's foundational uh, for a lot of aspects in health. One of which will be helping. As you said, when we were doing night shifts, I mean, it's one of the most unhealthy things we used to do. And um, my bowel habits would be all over the place after a night shift.

Dr Rupy: I mean, even anecdotally now, whenever, I know you went to Australia recently and you're about to go to Australia again, as am I. Um, but when I went to LA in summer, like my after that flight, for the next couple of days, I am constipated. I just can't go. And I'm a very regular person.

Dr Angad Dillon: And what do you do? How do you manage that?

Dr Rupy: So there's a few things. So A, I try and get into a regular um, eating pattern, first off. B, I don't drink.

Dr Angad Dillon: Hold on, hold on, pause there. So a regular eating pattern. So do you make, do you make use of the kind of gastrocolic reflex? This is another thing. So what would you mean? So you're, so when you, have you ever noticed first thing in the morning, you have uh, a cup of tea, coffee or something to eat and then you'll be going to the toilet.

Dr Rupy: Yeah.

Dr Angad Dillon: Yeah. So that's your gastrocolic reflex. Your your stomach is getting stretched, that's sending a signal to your brain, vagus nerve, that's sending a signal down to your rectum to defecate, right? So you can kind of use that as a hack. So, so how can you stimulate and trigger that gastrocolic reflex? Uh, something warm, something a little bit acidic, so coffee, that's the classic one. A lot of patients say to me, doctor, I have my coffee, if I don't have my coffee in the morning, I'm not going to the toilet. Yeah, yeah, yeah. Um, and um, yeah, the stretch. So, um,

Dr Rupy: That's amazing. I didn't realize that. I mean, I try and do that, but like I I try and maintain my my routine in the in the new time zone uh, according to the local time as well. So, but even that, like even me having my regular coffee and my regular breakfast when I'm uh, what, six hours ahead or six hours behind, regardless where I am, it doesn't have the same effect. It doesn't encourage me to go to the bathroom straight away. And I just have to wait for my gut to just realign. But there are a few other things that I do just to sort of like speed up that process.

Dr Angad Dillon: What are the other things?

Dr Rupy: So the other things are, um, I try and increase my fiber intake. So I will take a fiber supplement in the mornings along with my breakfast. So that would be a psyllium husk.

Dr Angad Dillon: Lovely.

Dr Rupy: Uh, and I will talk about psyllium husk in a bit. Psyllium husk, uh, flax, and I try and bump up my my general like overnight oats with a bit of chia as well.

Dr Angad Dillon: Oats, yeah, lovely.

Dr Rupy: Yeah, yeah. So oats, you know, beta glucans, chia with those the mucin, the mucilage production. So I I I would tend to have that in the morning, but I would be a lot more cognizant of it.

Dr Angad Dillon: Chia seeds.

Dr Rupy: Chia seeds, yeah, absolutely. I avoid alcohol because any amount of dehydration would

Dr Angad Dillon: And interruption of sleep.

Dr Rupy: Exactly. Yeah, so I would avoid alcohol on the plane and in the local uh, area. And the other thing I do is um, uh, I try and drink more water. I'm generally very well hydrated, but I try and drink more water when I'm in the local um, uh, when I've arrived at the local area because I just think that's going to help things move along.

Dr Angad Dillon: The flight itself is going to have to be.

Dr Rupy: Yeah, exactly. Yeah. And I'm really bad. I I I drink loads of red wine on the flight and just knock out for the flight. But that's probably the worst thing you can do.

Dr Rupy: Yeah, I know. I hate, I can't do that anymore. No way. I mean, it affects me when I'm in flight as well, but also now we have one year olds, like getting there and you've got a little bit of a hangover. I can't do that.

Dr Angad Dillon: Thank God, my wife's already taken the kids to Australia, so I get to fly by myself.

Dr Rupy: Yeah, you're lucky, you're lucky. I can't be, I can't do the same thing. I haven't convinced Michelle to be able to do that. Uh, but yeah, so those are the things that I do when I'm in a new uh, local. Do you have any hacks when you're traveling?

Dr Angad Dillon: Uh,

Dr Rupy: Do you take any supplements when you arrive in the like if you're going to Australia in a couple of weeks, are you going to be taking any supplements to keep your gut in order?

Dr Angad Dillon: The only supplement I take is on your advice, a bit of creatine. But that's I don't even take that all the time, only when I'm training.

Dr Rupy: Training. Okay, yeah, yeah, yeah.

Dr Angad Dillon: I have tried bumping up the dose a bit actually. And I suppose I have felt, for me, I don't know if it's placebo, maybe it's a bit of a, I feel maybe just a bit of an energy boost, mentally I'm not as tired. Yeah, yeah, yeah. Could just be placebo, I don't know.

Dr Rupy: Yeah, it could be placebo, yeah. I mean, like, I I personally have felt it, but again, it could be placebo. I'm doing a whole bunch of other things as well. I've increased my fish oil intake, I've increased my vitamin D dose. I'm actually experimenting with multivitamins at the moment. I know that I've said on previous pods that I'm not a fan of multivitamins. I don't think the evidence is there. But we had a recent podcast on and she pointed me in the direction of some other research that I hadn't come across before, some RCTs, and she's done it really well. And they're very like broad spectrum, high dose multivitamins. And there is a mechanism behind how it might be having a positive impact on brain health, particularly if you're in a stressed state. And I guess like the last year with a new kid, it's been very stressful from a sleep point of view, but also just organizing and business running and all the rest of it. So I'm experimenting with that at the moment as well.

Dr Angad Dillon: It's all very interesting. And uh, we haven't even talked about probiotics yet, but I mean, these are also things to be considered. My my only caveat would be, I suppose in in a big cohort of patients I see with constipation, a lot of it is uh, irritable bowel syndrome. And I think there's this fine uh, balance to be had between over medicalization and um, uh, focusing too, being too restrictive on what you can and what you can't have. Because a lot of the patients I see, they'll say, look, doctor, I've excluded this, I'm on this diet, I've I'm really super careful. I avoid all my trigger foods, but that in itself is a big stress. I mean, I'm lucky, right? I I I I my gut health has been reasonably good. So food for me is one of the most enjoyable things in life. I live for food. I'm a complete foodie, right? And so to imagine having the stress of when you're going out to a restaurant, having to constantly think about what you can and what you can't eat and constantly thinking, okay, which supplement should I be on, what supplement should I not be on. That in itself can lead to a whole degree of uh, health anxiety and stress and worry, which in itself will drive that gut brain axis to to affect gut motility and perceptions of pain, visceral hypersensitivity. So there is a fine balance to be had. And so, and the other thing you've got to remember, and this is underappreciated, if you look at the kind of big studies, the the placebo response rate in these functional disorders is huge. It's like 30, 40%. Why is that, right? So if I gave you like a a gut stimulant or a sugar pill, the sugar pill, 30, 40% of the time is going to be making a difference.

Dr Rupy: That's incredible.

Dr Angad Dillon: It is. And it just it just goes to show uh, how important the gut brain axis is, right? And and and it'd be interesting to get your thoughts on this as well about things like how can you hack the gut brain axis, right? So it basically comes down to the the vagus nerve, right? That's like the main highway between the uh, the brain and the gut. And you remember from med school days, we learned about uh, sympathetic system, parasympathetic system. So I hope I'm not getting this wrong. Sympathetic will be your fight or flight. So I would have had a bit of sympathetic uh, activation before I started this, right? I was getting a few IBS type symptoms. And then your parasympathetic will be your recovery, rest, restoration. Um, and so how can you hack getting more into away from fight or flight, hypersensitivity, gut activity to a more uh, parasympathetic drive. And it's by activating the vagus nerve. How can you activate the vagus nerve? Simple hacks, deep breathing.

Dr Rupy: Yeah, literally what we're doing before the pod.

Dr Angad Dillon: Before we started the pod. And you felt calmer, I felt calmer. Yeah. Um, uh, so yeah, so diaphragmatic work, deep breathing. Um, uh, what are the other things? Um, there's the Valsalva movement. I mean, I wouldn't recommend people.

Dr Rupy: Yeah, so you block your nose and you breathe against uh, um, resistance, so you're not breathing out at all.

Dr Angad Dillon: But yeah, not very practical. You're not going to get. But but yoga involves exercise, movement, uh, breath work. Um, and the other added benefit with yoga is, which we haven't talked about yet, is is the whole idea of movement. Movement is going to be helping with constipation. And you asked me earlier about bowel prep. There was a study, believe it or not, not long ago in India where they, it was a retrospective study, so take it with a pinch of salt, right? It's not high quality, but they got patients going in for colonoscopy to have four glasses of warm salty water and then um, perform, I'm not going to remember, I'm going to butcher the name if I try and say it, a certain type of yoga. And they and then they looked at how good the bowel prep quality was. So these are they've not had bowel prep. They've not had any laxative. It's just warm salty water and doing yoga. And they've managed to clear out their bowels. I mean, I think it was like 99% adequate bowel preparation with no bowel prep.

Dr Rupy: Really?

Dr Angad Dillon: So, take it with a pinch of salt. I'm not saying you don't need your bowel prep for colonoscopy, but it just shows the importance of movement. And in that type of yoga, there were five holds or positions, asanas, I think they're called asanas. And it's exactly what you would imagine it is. It's forward folds, side twists, deep squats, all things that are going to get the abdomen activated, abdominal muscles activated, diaphragm working, increasing abdominal pressure, getting things moving. Um,

Dr Rupy: It's so, you know, there are Ayurvedic practices for constipation. I think they call it Abhyangam. And it's a abdominal massage. And when I heard about this, I thought this is like some some some rubbish, you know, how are you going to literally like massage your constipation away? But the positions that they get them in for this particular massage is really uh, impactful. And it's literally what you were saying, twists, crunches, and there's even abdominal massages as part of constipation relief that are recommended by the NHS. We actually did some research and we found that like uh, hospitals like district general hospitals up in the north are recommending these different like practices for people with constipation.

Dr Angad Dillon: It totally makes sense.

Dr Rupy: It does, yeah.

Dr Angad Dillon: So that's another thing for patients in their armamentarium, right? We've talked about sleep, diet, fiber, movement.

Dr Rupy: I have noticed, and so there's a lot of anecdotes going around here today, but I think it's really important to tell personal stories. When I don't exercise, I get constipated because my body is so habituated to movement, if I take that stimulus away, I get constipated. So I think it speaks to like the power of movement. So look, we we've talked about so many different things here. So there's the diet and lifestyle uh, stuff, the soluble, insoluble fiber, supplements, sleep, stress. I want to just double down on stress a bit more because before we talk about stress, there was one big one in diet which um, is something I recommend to a lot of patients and it's kiwis. That's the real hot thing. Everyone you'll go online, my dietetic colleagues, I read their letters and it's always two kiwis a day, right? And um, that is because kiwi is a great source of soluble fiber. So remember we talked about soluble, insoluble. But when it comes to fiber, the other thing that catches people out is you get highly fermentable fibers and not so fermentable fibers, right? The highly fermentable fibers, believe it or not, are important because that's what feeds your gut microbiome. It's like the prebiotic stuff for them. But in that process, you get a lot of fermentation gas. So it can worsen people who've got constipation with abdominal pain. But kiwi is a soluble fiber, but it's not so fermentable. So excellent for constipation. There's a very elegant study showing that kiwi works very well. Um, the caveat to that is that the people who did that study, the the the funders, the sponsors just so happened to be the biggest sellers, marketers and distributors of kiwis in the world. But that's not to take it away, not to take anything away from them because they've done the study and they've demonstrated that it really works. But the only caveat I'd have is that yes, take kiwi, but I'm sure if the biggest distributors of mangoes or papayas or prunes did the study, they'd also be able to demonstrate that it works. So you've got lots of different options.

Dr Rupy: Yeah, yeah, yeah.

Dr Angad Dillon: You've got different options. But I just wanted to mention that because kiwi is um, it's a it's a big one. I I really do recommend. And patients always ask me also about the skin issue, whether skin on, skin off. The study that was done didn't use the skins.

Dr Rupy: Did?

Dr Angad Dillon: Didn't.

Dr Rupy: Oh, didn't use the skins. Oh, really? Oh, interesting. Okay.

Dr Angad Dillon: But I mean, if you want the extra roughage, you might as well. I personally, I love kiwis, but I wouldn't eat the skin.

Dr Rupy: We actually have a kiwi smoothie on the Doctor's Kitchen app and it was great to get you moving. And you take the skin off? No, I think we use the whole skin actually. But it's personal preference. But the thing is, I personally,

Dr Angad Dillon: So why don't you take that when you've been traveling in the morning?

Dr Rupy: That's a good point. You know what, I haven't, I haven't. I guess like whenever I go somewhere, it depends on whether I can actually get kiwis there. Um, so I just tend to

Dr Angad Dillon: Green kiwis is what they used in the study.

Dr Rupy: They use green kiwis, yeah, yeah. We use green kiwis in our smoothie as well. But I mean, any, I mean, like, yeah, you can use prunes, you can use berries. I mean, I'm sure there are similar qualities of the type of fiber.

Dr Angad Dillon: Yeah.

Dr Rupy: But we'll talk about specific foods in a bit. Um, uh, I want to talk a bit about stress, right? Because I know when we've chatted before about the patients that you see, particularly in private, you know, it's quite hard to have that conversation where you're trying to suggest to the individual that there is something wider going on beyond a mechanical or a physical issue going on in their in their body. And a lot of it is psychological. And I think we really need to lean into this in terms of like how it can lead to a number of different symptoms, one of which is constipation. You mentioned it earlier, like this sort of visceral connection that we have, the gut brain axis. Can we dive into that a little bit more?

Dr Angad Dillon: It's not just private, it's not just private patients. It's all NHS. As a consultant gastroenterologist, you have maybe 15 to 20 minutes to spend with a patient, right? So your priority has to be excluding bowel cancer, excluding inflammatory bowel disease, excluding the things that really need urgent attention. And if I'm being frank and honest, as general clinicians, it's very hard to unpick the more deeper issues, the more holistic approaches. I mean, we've, I don't know how long we've been talking now, but we've talked about so many different things. It's very hard to convey that to a patient. Um, the psychological aspect is huge. Absolutely huge. Um, and it it was bringing it specifically to constipation, one thing I always try and talk to about uh, when I'm dealing with patients who are who are describing constipation is I always ask them to kind of try and reflect back, go back in time. Um, uh, and have there been any, like a big one is toilet phobias. And it might not even be immediately apparent to the patient that they have it. I mean, I remember in secondary school, um, the toilets, the toilets that were at the school, they were those old school style ones where you know, the bottom quarter is missing and the top is missing. So you can see your feet when you're sat on the toilet. And I remember going like one of my first days at school and the kids all went in and they could see this kid on the toilet and they all started laughing and throwing stuff over. How traumatic must that be? It didn't even happen to me, but I was traumatized by that. And I I never ever used the school toilet ever, just a fear of being bullied. And so that will lead to set in motion behaviors where you are putting off that natural rhythm or or or the circadian rhythm, the gastrocolic reflex we talked about. Your your your body's giving you the signal you need to go to the toilet, but you're holding off, wait till I get home or wait to somewhere where I feel a bit more comfortable. That is going to lead over time to your colon being able to accommodate more stool to to get used to that feeling. And over the years can compound. It's not always a simpler case of um, toilet avoidance behavior or toilet phobias. You've the the also the the other serious thing no one likes talking about is is is trauma, abuse, sexual abuse in childhood, um, which can lead to behaviors where uh, you have what's called dyssynergy. So something we need to talk about the pelvic floor, right? So dyssynergy, dyssynergic defecation. So the muscles that are controlling defecation, the anal sphincters, um, and there's a dyssynergy between the muscles and sphincters working with your abdominal wall muscles and intra-abdominal pressure. So essentially, you've got a clenched back passage and you're trying to push against that. There's a you need to relax that and then push. And there's that dyssynergy, right? Um, so that coordination between that is off. That coordination. And that is not usually that something it's not something that just comes on overnight. You don't suddenly have dyssynergic defecation. It's it's usually a process that you need to unravel that's been going on for quite some time. Um, and there are uh, a lot of psychologists, gut specific uh, psychologists that are very and even gastroenterologists with dedicated uh, interest in neurogastroenterology who have more time in clinics, they they they they they reserve more time to to kind of go through all this and unpick this with patients. Um, but that remember when we first started talking, we talked about slow transit. This would be the functional outlet uh, um, functional outlet obstruction. So there's not something blocking you there. There's that um, dyssynergy. The other thing to think about is actually structural problems. We haven't talked about that. So when I'm taking a history from a patient with constipation, no one likes to ask this question and patients are usually embarrassed or scared to divulge this information, but they use they digitate, they're using their finger to actually help the passage of a motion. And not just via the back passage, in women sometimes it's through through the vagina. And they're actually what's happening there is they're they're pushing against the posterior wall and that's adjacent to the rectum and that's helping with the passage of a motion. And that's usually a structural issue. So they'll get what's called a rectocele. So the part of the rectal wall is is weaker and so when you've got that intra-abdominal push, instead of the stool coming out, it's being pushed to the side.

Dr Rupy: Okay. So instead of the the the poop literally going straight down, it's going to the sides.

Dr Angad Dillon: Exactly. And is that a sometimes a side effect of natural birth or lack of pelvic floor exercises during, you know, adulthood?

Dr Angad Dillon: I think so. Yes. Um, it's not my real area of expertise. What I would do with these with patients who are describing that, I do some very specific kind of tests. If you want to talk about them, we can, things like anorectal manometry, defecating MRI scans, but this usually is managed best in what's called a pelvic floor MDT. Pelvic floor multidisciplinary team where you've got colorectal surgeons. But absolutely, things like traumatic births, um, and even lack of muscle mass. It's so important to have strong pelvic floor muscles.

Dr Rupy: Yeah, yeah. I mean, even as men, we're not taught to do pelvic floor exercises and it's so important from, you know, urinary incontinence point of view, uh, even sexual health point of view. You know, it's all about squats and bigger muscles and stuff, but those those those muscles and the the the techniques of like uh, push and pulling against um, the, you know, the the feeling of uh, of evacuating your your bladder. That kind of stuff, that's what we need to to do more of.

Dr Angad Dillon: It reminds me, um, when we're talking about pelvic floor also, we haven't mentioned the squatty potty, right?

Dr Rupy: Yeah, yeah, yeah. I want to, I've got that on my list. Don't worry. I got my we definitely need to talk about squatty potty.

Dr Angad Dillon: This comes back to what we were talking about about uh, evolutionary legacy.

Dr Rupy: Yes.

Dr Angad Dillon: Or not so much actually, because this is it's kind of. So human beings didn't evolve in the plains of Africa with nice porcelain toilets to sit on, right? We squatted. That's the human body, that's how the human body is designed to defecate. And the reason for that is because of of of the angle. So you've got your anal canal and then you've got your rectum and it's at this kind of not complete right angle, but say it's like that. And then you've got what's called the puborectalis muscle which uh, you need to relax to straighten up that angle. How do you relax that? By getting your feet raised up and your knees uh, higher than your waist. And so the squatty potty is just a stool. It's literally just a stool so that you can mimic that squatting position. Yeah. Um, I did used to use it just because I I I I'm a strong believer, I advocate for for for for toileting in that way. If you're my wife doesn't like having a stool in our toilet, in the bathroom, but I'm sure you can get nice expensive ones which you can fold away and hide away. But um, but yeah, absolutely, particularly if you're someone who's straining, who has issues with hemorrhoids, uh, you've got that tenesmus symptom, that feeling of incomplete evacuation, that is a drug-free, cheap way of solving that problem.

Dr Rupy: So in in order of preference, right, what what are the like top three things that you would say people should focus on out of all the things we've just talked about, the fiber, magnesium supplements, uh, sleep optimization. I mean, they're all very important, but if there were like three things that you'd be like, like people need to focus on these before they start doing anything different or anything weird and wonderful, what would those be?

Dr Angad Dillon: For someone with severe constipation, uh, let's how can we put these into buckets? Um, diet, so getting your recommended fiber in diverse sources and then supplementing with ispaghula husk, soluble fiber. Best evidence right now.

Dr Rupy: Ispaghula husk is psyllium husk, right?

Dr Angad Dillon: Psyllium husk, same thing. Yeah. Fybogel. It's all just but the caveat to that is a lot of doctors and GPs will just go go for it. Start slow and build up. Yeah. Right? Because you need to it can have the bloating, pain, that kind of thing. Yeah. Uh, so that's the first bucket, um, diet. Uh, what's the second bucket? Um, movement. So movement that would include keeping your legs raised, yoga, exercise, um, breath, I'd include in that bucket breathing. Diaphragmatic work. Yeah. Um, and then if those two have failed, um, I suppose we haven't actually talked about um, medication because there is a role in medication.

Dr Rupy: Oh, we'll definitely talk about medication. Yeah, yeah, yeah.

Dr Angad Dillon: So so in people who are really struggling, they've taken the holistic approach, they've got their diet right, they're moving, um, they've addressed, they're trying to address stress and sleep, you've got to think about drugs. And my first line drug would be something that is gentle and is not stimulating the bowel, it's kind of mimicking what fiber is doing. So, so what's called PEG, so your Movicol, um, Movicol and uh, Laxido. These are osmotic laxatives. So all they're doing is just drawing more water into the bowel to get things moving. Very safe, you can use them long term.

Dr Rupy: Does that dehydrate you as you're taking water out?

Dr Angad Dillon: No, but I would always, yes, it can. So I would always say you make sure you're drinking plenty of water with it. Um, sometimes I see a lot in primary care doing it, I don't like doing it the other way. So a lot of patients I see they've been taking things like senna, bisacodyl. Um, it's not that I'm against those medications. I don't want to scare patients who are on those, but it's just I would prefer to do things the other way around because senna, bisacodyl, these are stimulants. So they're stimulating your your your bowel to to move. I think it should the way you should do it is uh, the the osmotic laxative first, if that doesn't work, and then that's an addition if it's not working. That's another thing to to to mention to you, mixing and matching laxatives. A lot of patients will try one and give up and they'll come into clinic and they they want more done. You need the combination. So osmotic laxative first, if that doesn't work, add in uh, a stimulant like senna. A lot of patients will get confused with senna because senna is uh, a supplement which you can find over the counter. But those are very low doses and the evidence is they don't really do much.

Dr Rupy: So the over the counter senna that you can find, senna cot and things like that.

Dr Angad Dillon: Um, the senna you want is the one that's prescribed by the the GP. That's the that's the proper dose and that does have evidence that it's going to work. Uh, but I'm slightly hesitant about senna bisacodyl. Um, I could be wrong, I could be proven wrong. Uh, just because it's a stimulant and I and there is this feeling of of could patients be getting used to it or dependent on it. I don't think that's been shown in the evidence. And certainly there's not what's called um, tachyphylaxis, which is where you become dependent on higher and higher doses of it. That's definitely not the case. Uh, but if I do see patients who who say to me that they they need to keep taking senna. It's not something they can stop using. And I just feel a bit more uncomfortable about being on that on long term. But if it works for you, absolutely, that's fine. Lactulose is something GPs love to prescribe. Lactulose, absolutely not. Stop that straight away if you're doing lactulose.

Dr Rupy: Really?

Dr Angadillon: Lactulose is very good for people who have um, um, liver disease and they suffer from what's called encephalopathy. So they've got high levels of ammonia in their in their blood. They get what's called a flap, remember in medical school we used to check for the flap. And they get kind of um, uh, cognitive uh, changes. Um, and the reason for that is because they've got um, high levels of ammonia. So lactulose works very well because it implements the metabolism uh, of the gut microbiome in producing those compounds that lead to encephalopathy. But the problem with lactulose is sugar. And it's very bloating. So in your normal patient without liver disease who's trying to manage their constipation with lactulose, it's going to give them a lot of pain. It might get them have a movement, but it's going to cause a lot of bloating.

Dr Rupy: What so what what kind of medication is lactulose? Is that a stimulant or is it an osmotic?

Dr Angad Dillon: Lactulose is um, it's a sugar. So I think it's again drawing water into the bowel, uh, but it has um, an effect on the microbiome uh, which is beneficial for patients with encephalopathy.

Dr Rupy: Got you. Okay. So lactulose only if you have that.

Dr Angad Dillon: It's I I use that in patient in liver patients. I don't use that for patients.

Dr Rupy: You don't use it for anyone else. What about so?

Dr Angad Dillon: It's very commonly prescribed. It's very commonly prescribed. Like even those with opiate medications as an example. They they tend to give lactulose.

Dr Angad Dillon: But it's not bad, it's not harmful, but it's going to worsen your bloating.

Dr Rupy: Yeah, yeah, yeah. And that's the big thing. And I guess if you if you've got the the bloating symptom as well with constipation, then you want to because I remember lactulose, I mean, we used to give this out like smarties. Yeah, yeah, yeah, yeah. Wow. Okay, great. Well, good good thing I'm not prescribing uh, lactulose anymore. Um, are there any other supplement or sorry, medications to this list?

Dr Angad Dillon: Magnesium oxide we talked to. Yes. Yeah, yeah, yeah. Um, just a few months ago, I think I mentioned the the um, British dietetic association did a very good meta-analysis. God knows how much work went into that. I think you might know, it was uh, Prof um, Kevin Whelan.

Dr Rupy: Yeah, King's group.

Dr Angad Dillon: You might have even had him on the podcast. It was his group that did it. Yeah, yeah. Oh, interesting. Yeah. Um, massive body of work, mate, like six years and they they've put together all the meta-analysis, um, and um, one of the ones that came out that was a bit of a surprise to me was magnesium oxide, how safe and good it was for managing.

Dr Rupy: What kind of dose are we talking about? Like two to 400 milligrams, something?

Dr Angad Dillon: 0.5 milligrams to uh, 1.5.

Dr Rupy: Wow. Yeah. Really? Yeah. Gosh. I mean, it must be grams. We tend to, we tend to see supplemental versions of that.

Dr Angad Dillon: I need to double check that.

Dr Rupy: I'll double, I'll double check that. Yeah, yeah. I'm I it'll probably be in the 4 to 500 milligram range, I reckon. Just from my my knowledge of that. But we'll double check.

Dr Angad Dillon: It's 0.5 to uh, 1.5. Whether it's grams or milligrams, I can't remember.

Dr Rupy: Okay, okay. Um, so magnesium, that's really interesting. It's really interesting.

Dr Angad Dillon: And so the other things in that big meta-analysis, specific things, ispaghula husk, number one. Yeah, yeah, yeah. Magnesium oxide, rye bread. The issue with rye bread is that you need like 10 slices a day. Who's going to be eating 10 slices of rye bread? So maybe not rye bread.

Dr Rupy: Okay, yeah. Um, uh, what were the other things? Um, uh, oh, I'm having a bit of a blank out. Uh,

Dr Rupy: We can link to this RCT. I definitely, sorry, the um, uh, meta-analysis. I definitely want to have a look at that.

Dr Angad Dillon: Probiotics was disappointing.

Dr Rupy: Oh, let's talk about probiotics actually, because

Dr Angad Dillon: It's disappointing in the meta-analysis.

Dr Rupy: Really? I mean, there are some some signals, certain strains are going to be beneficial, but overall, not much impact.

Dr Rupy: Very interesting. Okay.

Dr Angad Dillon: Overall, not much impact. And they included everything. They included the studies which are looking at single strains, multi strains. Yeah, they included everything. So it's interesting that. Mineralized water came out quite good.

Dr Rupy: Really? Wow.

Dr Angad Dillon: Yeah. Mineralized water.

Dr Rupy: So the so the water with a bit of magnesium and other salts in.

Dr Angad Dillon: Yeah. Interesting.

Dr Rupy: Okay. Do you do mineralized water? Do you have a purifier that you add mineral salts to or do you?

Dr Angad Dillon: I have a, I just use a Brita filter, but maybe I need to start drinking more mineral water from bottles.

Dr Rupy: Yeah, yeah, yeah. Interesting. I mean, it's a lot more expensive, isn't it?

Dr Angad Dillon: The thing about this big meta-analysis which was a bit disappointing is that not one randomized control trial was included which talked about broad high high fiber diets. They just aren't, it's not their fault. They just haven't been the studies. So like just a broad, so you know earlier we talked about the importance of diverse sources of fiber. They there are no studies looking at kind of like Mediterranean diet or just broad diets. And so the message, my interpretation, my message from that meta-analysis is yes, the general advice of get more fiber in your diet, it still applies, but gastroenterologists need to be giving a bit more tailored on top of that. So the specific things in constipated patients is your soluble ispaghula husk, your magnesium supplements, your hydration. Um, that that's the overall message that I've rye bread, um, there's another one, um, partially hydrolyzed uh, guar gum.

Dr Rupy: Yeah, PHGG.

Dr Angad Dillon: Yeah, that's that's a bit trending at the moment.

Dr Rupy: I'm finding that in lots of different supplements. In fact, we got sent a bunch of supplements and I've seen that as the top thing.

Dr Angad Dillon: And so that again, it has those two criteria, soluble and low fermentable.

Dr Rupy: Yes, yeah, yeah. So this particular brand that sent this over, they did a low FODMAP blend with a bunch of different herbal uh, additions as well that might be quite relaxing for the gut. And look, as I was, as we're talking about this, and this is the reason why, you know, I love doing this podcast, right? Because if you think about all the things we've talked about before we got to the medication bit, it's so hard to pack this in, even with the luxury of 15, 20 minutes in a in a gastro consultant's uh, consultation room, let alone a GP's seven to eight minutes. How are you going to get through all this with a patient?

Dr Angad Dillon: How are you going to talk about all this?

Dr Rupy: Like we've got all the different types of fiber, we've got hydration status, what's going on with your sleep? What's going on with your stress? Are you breathing properly? Are you moving? Have you tried yoga? What about pelvic floor exercises? Stool, as in like a a potty uh, what do you call it?

Dr Angad Dillon: A squatty potty.

Dr Rupy: Squatty potty. All these different things. Kiwis, like how are we going to fit in a conversation about these things before we get to Movicol, Senna? And that's why

Dr Angad Dillon: Thank God for dietitians. That's why dietitians are so helpful as working alongside gastroenterologists.

Dr Rupy: Yeah, or they should be working alongside GPs and everything, but there's just not many of them out there. And they don't have the, well, the NHS doesn't have that forward thinking about diet and and lifestyle that dietitians and and other, you know, health coaches could could potentially offer. Um, okay, so we talked about medication, we talked about all these different things here. Um, what are some of the red flags? I want to make sure that we we tick off some of the red flags.

Dr Angad Dillon: Red flags. Okay, so at the beginning we talked about how overall, in my opinion, constipation is not as bad as when you have loose stool or increased frequency. So it's not really classically a uh, a worrying sign for bowel cancer and constipation in itself is not an indication for having a colonoscopy. The red flags, I would say was remember I mentioned tenesmus. So that persistent feeling, not comes and goes, that persistent feeling of something that is there that you just can't get rid of. You need to have some kind of direct visualization. So the GP, the gastroenterologist needs to be examining the back passage or doing a camera, a flexible sigmoidoscopy to have a look. Uh, what are the other red flags? Weight loss, um, uh, altered blood in the in the stool. So anorectal bleeding, bright red blood on the tissue paper, most likely is from trauma to the back passage or hemorrhoids, classically, right? Altered blood, so not fresh, kind of mixed in with the stool, a bit darker, that is a red flag, absolutely, 100%. Um, iron deficiency anemia. Iron deficiency anemia is a big one. Anyone who has iron deficiency anemia, that is an urgent referral to see a gastroenterologist, colorectal surgeon. Um, what are the other red flags? Uh, so we said weight loss.

Dr Rupy: Yeah, we talked about weight loss.

Dr Angad Dillon: The remember the change. So if someone is uh, normally was once a day like clockwork and for three to six weeks has suddenly now found they're going once every uh, three times a week or or less, uh, that would be a little bit of a red flag for me, that sudden uh, change. Um, abdominal pain. Yeah. Uh, which is persistent abdominal pain. Um, IBS, the classic is the intermittent nature of it. So, doctor, some days it's really bad, some days it's okay. I noticed when I last went on holiday, I was reasonably well, but now I'm back, back at work, my symptoms have come back. That that kind of fluctuating is reassuring. The progressively worsening symptoms. So pain was there, it's got a bit worse, it's got a bit worse, it's not going away. That's a red flag for me.

Dr Rupy: That's a red flag. Okay. And what about a mass? Like is that a mass? Yeah, like a like a mass that you can feel.

Dr Angad Dillon: Usually when I've been referred patients with a mass, you feel it's what's called a lipoma, that's the commonest thing. You feel this lumpy soft thing on the. But a mass uh, on on examination, uh, you need to have that checked out 100%.

Dr Rupy: Let's talk a bit about uh, colon cancer um, and the the increase in cases. Are you seeing that? Is this born out in the studies that we're seeing a higher incidence of colon cancer?

Dr Angad Dillon: Colon cancer is my niche. That's I do a lot of what's called bowel cancer screening. So bowel cancer screening is a fantastic thing we do in this country. Uh, when you are, it used to be 55, they've lowered it to 50 years old, you are invited to give uh, the government a bit of your poo. And they are looking for any traces of human hemoglobin via a test called a fit test, fecal immunochemical test. And um, if it meets the threshold uh, of a certain amount of uh, human hemoglobin, uh, it's uh, what's the number? I think it's 80 uh, micrograms per gram of poo. If you've got that much, then you will be referred for a colonoscopy. That's what bowel cancer screening is. You said something interesting about um, the increasing rates of it. In America, in the United States, they have lowered their threshold uh, for doing bowel cancer screening to 45. And initially I would have thought, what, it's America, their incentives are different. The more things you can do for patients, more insurers make more money, etc, etc. But actually it's based on data. They are seeing, not just they, the UK as well, are seeing a increase, it's not a big increase, but there is an increase in the number of cancers in younger patients. And it's not clear why, lots of different theories. I don't have the answer, but I would have thought a reasonable guess is the increasing rate of childhood obesity, uh, increasing use of antibiotics earlier on in life. Yeah. Um, changes in the gut microbiome with processed foods, um, lots of, particularly in America, high fructose syrups, all that stuff that they have in their drinks. Um, so yeah, so we are, there is a signal that we are seeing more cancer in younger populations. So eventually, I would have thought in the UK, I mean, we've only just reduced it from 55 to 50. But these are kind of arbitrary. They're just this is based on big data and epidemiological studies. Uh, when you, if you're 44, when you turn 45, you're not suddenly going to increase your risk. But these are just how these are just how they adjust these numbers to try and catch as many people as possible with bowel cancer within keeping it feasible to run a screening service.

Dr Rupy: Yeah, got you. Yeah. So there's a there's a a commercial or like a um, a national decision to be made at of like whether the costs spiral for the the the benefit that you're going to see in terms of life.

Dr Angad Dillon: And whether it's effective. Because you don't want to be performing colonoscopies on healthy people for no reason. You have to, I mean, this is a decision for the NHS, the statisticians to to to make sure that the balance is right, that economically and how many people you're going to pick up.

Dr Rupy: Exactly, yeah. And, you know, there is going to be always that trade-off between over investigating the potential risks of uh, colonoscopies and the cost consideration as well. Um, I don't know, and this is again, pure anecdote, but in my circle of colleagues and friends, I know personally four people under the age of 35 that were diagnosed with bowel cancer. And that that's been in the last 15, 20 years now. And like

Dr Angad Dillon: It's scary.

Dr Rupy: It's scary. And you look at some of the numbers and it's increasing and I and these weren't obese people. I don't know about their antibiotic history. I don't know about their exposure to processed foods. I don't know about their exposure to things like microplastics and pesticides and all the rest of it. But it is a worrying signal.

Dr Angad Dillon: It is a worrying signal. Um, you're not alone. I see a lot of patients who delving more and more into the history, they've had a friend. And that's put the fear of life in them. And they just want the reassurance. So they actually don't really have many symptoms. Sure, yeah, yeah. Um, it's not unreasonable. And I I do bowel cancer screening. So I see 50 year olds who have no symptoms. They are well. They don't have constipation. They don't have loose stool. They don't have blood. And there is a early tumor sat there.

Dr Rupy: That's the thing.

Dr Angad Dillon: Scary.

Dr Rupy: Yeah, yeah. So in in so let's imagine, right? Uh, I turned 40 this year, right?

Dr Angad Dillon: As do I. Happy birthday, mate.

Dr Rupy: Who would have thought 40 years old after medical school, 20 years later, we're we're sat here doing a podcast.

Dr Angad Dillon: Sleep deprived.

Dr Rupy: Yeah, sleep deprived with one year olds. Um, so yeah, so so as a 40 year old, is it a pragmatic decision for someone like myself who's otherwise fit and well, no symptoms, eats a high fiber diet, to do regular colonoscopies every two or three years, just in case, just to pick up some of those pre-cancerous lesions. Or maybe it's

Dr Angad Dillon: It's a it's an interesting question. I've thought about this. Should I have a colonoscopy? Probably not. I think you have to be honest with yourself. Are you having symptoms? Have you had a change in bowel habit? Have you had any unexplained uh, symptoms? Um, I don't think rushing in with a colonoscopy, I I mean, I am a big advocate of colonoscopy. I think it's a great test because it's one of those few things in medicine you can do which is not just diagnostic, you're not just finding something, it's therapeutic. So if I performed a colonoscopy for you, um, it may very well be normal, but you could find what are called polyps. So these are small uh, little growths in the in the lining of the bowel, kind of like, you know, on your skin you have moles, similar to that. Uh, they're not cancerous, but they are the precursor lesions. They are pre-cancerous lesions. So over years with increasing kind of incremental changes to the to the genetics, to the genes, and that progresses from uh, what's called low grade, we don't need to go into technical, but low grade dysplasia, high grade dysplasia, cancer. Um, doesn't happen for all polyps, but

Dr Rupy: So you can you can feasibly have polyps there and they won't do anything. They won't change or over a long enough time period.

Dr Angad Dillon: Over a long enough time period, they will change. There are things called hyperplastic polyps. These are completely benign, so they don't have any risk of ever turning into bowel cancer. But adenomas and something called serrated polyps, they do, it's small, but there is a risk. And they've been very elegant studies showing um, that by removing adenomas, you are directly reducing your risk of you going on to get bowel cancer. So having that colonoscopy now is a therapeutic intervention to reduce your risk of getting bowel cancer.

Dr Rupy: Yeah, yeah, yeah, yeah.

Dr Angad Dillon: So I'm a big advocate for colonoscopy. Would I say everyone who's 40 years old gets a colonoscopy? No. I think that's not a good use of resources.

Dr Rupy: So this is the the very novel and interesting thing about colonoscopies because it's not only screening, it's treatment as well, right? So when you're doing a proper colonoscopy,

Dr Angad Dillon: And you remove a polyp, that is a therapeutic intervention.

Dr Rupy: Exactly, yeah. And and just talk people through the the sort of general progression. You mentioned it there, but I want to I want to get this clear in people's minds. So you have pre-cancerous lesions, things like polyps that can turn into the cancer.

Dr Angad Dillon: It's called the adenoma carcinoma sequence. You have a benign polyp, uh, you get uh, incremental insults to the to the genetics, to the genes, and that progresses from what's called low grade dysplasia, high grade dysplasia, cancer. Doesn't happen for all polyps, but

Dr Rupy: So you can you can feasibly have polyps there and they won't do anything. They won't change or over a long enough time period.

Dr Angad Dillon: Over a long enough time period, they will change. There are things called hyperplastic polyps. These are completely benign, so they don't have any risk of ever turning into bowel cancer. But adenomas and something called serrated polyps, they do, it's small, but there is a risk. And they've been very elegant studies showing um, that by removing adenomas, you are directly reducing your life lifelong uh, risk of bowel cancer.

Dr Rupy: Okay, okay. So feasibly, let's imagine, right? Uh, that there is a way to do a colonoscopy every week, okay? And every, what's up?

Dr Angad Dillon: Start again. There's a you have someone is having a colonoscopy every week.

Dr Rupy: Yeah, let's imagine. This is just a thought experiment. So someone's having a colonoscopy weekly, right? Uh, not maybe

Dr Angad Dillon: You'd be pretty dehydrated.

Dr Rupy: I know, you'd be pretty dehydrated. But let's imagine you're doing a colonoscopy every week and you are capturing any element of cancer, any polyp, any anything, every single week and you're removing it. Does your risk of colon cancer go to zero? Put aside the risks of doing a colonoscopy, put aside all that. Does your does your risk of developing colon cancer in your life?

Dr Angad Dillon: I mean, yes, because you're doing a colonoscopy every week. So you're you're you're cancers don't pop out of magic.

Dr Rupy: Yeah. Okay. So so feasibly, if there is, if you're just thinking about the um, the risk uh, benefit ratio here, if you could do a colonoscopy at a time period, whether that's once every five years, once every 10 years, once every year, that there is a way in which you can capture any signals of early cancer such that you never have colon cancer in your life.

Dr Angad Dillon: Um, I know, I know you're we're not suggesting that people should do a colonoscopy every week. I don't want that.

Dr Angad Dillon: If you do a colonoscopy, if you have a good colonoscopy, not I mean, a person who is highly trained and is trained to detect polyps at a high rate, you would expect just by having one colonoscopy, all polyps that can be removed are removed. You have now protected yourself from developing bowel cancer. The time frames here is it's difficult to say. But polyps will grow, the time frame I would say between three and five years, you would expect maybe more polyps to have grown. So I don't think every month, every year is a sensible thing to do. Absolutely not. But you're forgetting one element here in that we've got a very good screening test that saves you having to have a colonoscopy. So back to your question about what would I do? Would I do a colonoscopy at 40? Probably not. What I would think about doing is the fit test.

Dr Rupy: The fit test. Yeah.

Dr Angad Dillon: Because what's happening, a polyp is secreting microscopic traces of blood, right? That's what the fit test is picking up. So if you can pick up traces of blood, yes, then have a colonoscopy. But if you've had, and I think there was quite a good study, I think from Scotland it came out not long ago, two fit tests that are negative, your risk of bowel cancer essentially is going to like 99% you're not going to have bowel cancer.

Dr Rupy: Right, right, right. Yeah, yeah, yeah.

Dr Angad Dillon: So what one, it's not great. You can have a negative fit test and still have bowel cancer. But two fit tests, you don't need a colonoscopy. If you have no symptoms, remember this caveat is always very important. Symptoms changes things. If you have symptoms, you need to be seeing your GP, you need to know if you've got iron deficiency, you need to have the stool test plus or minus a colonoscopy.

Dr Rupy: Yeah, yeah. Can you pay to have a fit test yourself?

Dr Angad Dillon: I need to do my research. I think you can. I don't think they're that expensive.

Dr Rupy: Yeah, yeah. I mean, it's a very simple test, right? You just put your poop in a, I mean, people are used to doing gut microbiome tests now these days, aren't they? So

Dr Angad Dillon: Gut microbiome tests, you're paying God knows how much money and they give you a 10 page report of every one of how many trillions of different bacteria. And the funny thing about those tests, right, is you've got your gut microbiome. What about your virome? What about your fungome? How do these things all interact?

Dr Rupy: Yeah, yeah, yeah. It's such a murky world at the moment.

Dr Angad Dillon: It's a multi-billion industry dollar industry.

Dr Rupy: Yeah. Is it multi-billion? Is it multi-billion?

Dr Angad Dillon: It must be, mate. Come on.

Dr Rupy: I mean, gut health probably overall is probably a multi-billion dollar industry right now.

Dr Angad Dillon: Don't get me wrong. I don't mean to be like facetious. It's a it's a really interesting area and especially with AI, big data. The next 10, 20 years are so exciting in what's happening. But but right now we're at the tip of the iceberg. We haven't got a clue really of what's going on.

Dr Rupy: Yeah, I think people really do miss out on that virome, fungome, uh, there's so many other microbes that are interacting.

Dr Angad Dillon: So if you fix your microbiome, how do you know what impact that's going to have on your virome? And what impact is that going to have on your fungome? And how it all fits together and how you feel?

Dr Rupy: Yeah, yeah. And the the advice is always the same. It's just diversify your diet, make sure you're hydrated, make sure you're removing all the junk.

Dr Angad Dillon: Which is frustrating for patients. And I've I've it's frustrating because

Dr Rupy: You must get asked for for a gut test all the time, right?

Dr Angad Dillon: Oh, I get, no, I don't ever do them, but I get patients giving me their 10 page report of what how much candida they've got in their stool. And I'm like, look, that's absolutely fantastic. So interesting. How can I action this for you? I'm sorry, there is nothing evidence-based I can action for you.

Dr Rupy: Where do you think the missing um, where do you think you're missing information about um, these gut tests for you to interpret them appropriately? Because there are people out there who are nutritional therapists, very experienced.

Dr Angad Dillon: Nutritional scientists who are who are at the forefront of this. And um, I think we will start being able to use precision um, precision treatment, precision microbiome uh, probiotics uh, with the help of artificial intelligence, big data, because it's so many variable moving, there's so many things that are changing and one thing it's it's bidirectional, right? So this thing impacts that, which impacts that, which impacts that. It's so hard to unpick and we're so early on in the understanding of it, but we'll get there eventually. Um, absolutely we'll get there. Right now, what's the missing thing? Um, it's the complexity of it. It's just unpacking the complexity of it and how because we're all different. So there isn't one right microbiome. What's right for me might be different for you. So it comes down to precision. And then you've also got to think about you and your genetics and um, and all these different pieces of the puzzle have to fit together before we can start making recommendations.

Dr Rupy: Yeah, you know, the interplay between our genomics, which are very important. I think they've sort of been like shoe to the side now that microbiome, the microbiome uh, studies are happening at the moment right now, but it all interacts with that and your stress levels, your epigenetics, yeah, exactly. Like there's so many different things. And so I think it's more of a computational problem. It's how you actually bring all these things together.

Dr Angad Dillon: Exactly right. It's exciting times because we're starting to get the tools to be able to do that. So very, very exciting, interesting times. But it's always a little bit, not a red flag, but just always for patients, just be a little bit wary when you're being promised these things like precision probiotics, precision this, we're not quite there yet.

Dr Rupy: Yeah, yeah. Do you use probiotics at all in your practice?

Dr Angad Dillon: I've played because I I I in in patients who have got IBS, um, and they've they've they've optimized a lot of the things we've talked about. Remember I said to you about the the functional studies showing the placebo rates of up to 30 or 40%. So what is if a probiotic is safe, what is the harm of trying it? And if it works for someone, sure. I personally have tried probiotics. It I didn't notice much difference, but I've had patients who have tried probiotics and it's really helped for specific things like my bloating got a lot better. Um, constipation I've not had much success with probiotics to be honest with you. Um, but when you do look at probiotics, my advice would be one, don't get the cheap things over the supermarket that are packed with sugar because yes, you're going to get some probiotics, but it's counterbalanced by the fact that you're having a lot of sugar, which is bad for your microbiome, right? So you want things that are going to do what they say, they're going to get to the gut. They've got lots of diversity because we don't know, we can't tailor precision yet, right? So you want diversity. Uh, you want lots of different uh, cultures, um, and uh, yeah, so the typically the ones I I've had anecdotal experience with patients really like Symprove. Uh, Symprove is a bit expensive and doesn't taste great. Uh, so

Dr Rupy: Maybe that adds to the placebo effect.

Dr Angad Dillon: Yeah, maybe.

Dr Rupy: The expense and the taste.

Dr Angad Dillon: Tastes like it works. Um, Optibac, uh, Bio-Kult is another one. I think Bio-Kult is the one I've used, cheap and cheerful. Yeah. Um, I've experimented with that. Um, hasn't done me any harm. I didn't start getting diarrhoea or abdominal pain, but I didn't notice a massive difference. Um, but for someone who is concerned about their gut health, if someone has had multiple courses of antibiotics, if they've suffered with things like tonsillitis in young at a young age and had recurrent antibiotics, um, then I think there's yes, a role for helping to uh, fortify your gut microbiome with probiotics. But the other thing you have to exhaust first is the is the natural way of doing it. I mean, you on your podcast talk loads about uh, fermented foods, kimchi, miso soup, sauerkraut. These are all things, natural ways of getting probiotics in. So why not exhaust the natural way of doing it first? Because there's going to be other benefits of those things that we don't even know about.

Dr Rupy: Do you subscribe to this idea that we should be uh, eating more in line with our cultural heritage? Like, you know, we both come from Punjabi culture, right? And like if you think about our traditional diets that our ancestors would have been eating, it would have been a lot of uh, whole wheat rotis, loads of lentils, loads of dal, like raw milk, all that kind of stuff.

Dr Angad Dillon: If I ate every, like my mom comes over maybe once a week on the weekends and leaves me some chole, some rajma, and some uh, so for for non-Punjabi speaking, that is chickpeas and kidney beans, right? The next day, mate, I'm farting for England, basically. I mean, come on, like, no, these are high FODMAP foods, right? So, so I I I I haven't seen any evidence about following cultural specific diets. I think I think I'm, like I said, a foodie. I love food and I like to experiment with all types of cuisines. And um, so I find it, I think, I think having having a diverse, different tastes and um, uh, this kind of thing is is super important. You've talked a lot about about about the the psychological importance of food, eating with people, being mindful when eating. We haven't even talked about that. So a lot of my patients, young professionals who have long hours, high stress, what is their diet? In their lunchtime, they're running off and getting a a salad and they're scoffing it down, ingesting a whole load of air, dumping all that food in their stomach and then they're working, they're in fight or flight, they're not rest and digest. That food is sitting there causing bloating, constipation.

Dr Rupy: Yeah, it's a huge, it's a big issue. I mean, like, you know, I used to be that person when I was working in the wards, just like grabbing something in the nurses station or running to the next patient, you know? I think we've all been there and if the the the more we educate people in the connection between their symptoms, their gut health and the manner in which they're eating, the better. So sometimes it's the case of not even changing what you're eating, it's just how you're eating. And the Mediterranean diet gets a lot of air time. I think some of the best parts of the Mediterranean diet are not even about the food, it's about the fact that you sit down, you have a conversation with someone, you know, you might have a glass of wine or water or whatever, but you're you're you're eating speed is going to be naturally a lot slower.

Dr Angad Dillon: Slower, more mindful. You're not distracted. You're going to, yeah, your body's going to be in rest and digest. That's all going to get processed. Your gut motility is going to be active. You're going to be making use of the gastrocolic reflex.

Dr Rupy: I wanted to ask you something. Mediterranean diet. Something that's not been looked at a lot in the literature for constipation is olive oil.

Dr Rupy: Yeah. Olive oil. I don't know about constipation, but olive oil is incredible.

Dr Angad Dillon: But it's a natural lubricant. I I mean, olive oil would surely be helpful for people who

Dr Rupy: All I know about olive oil is that it is, it's high in specific specific polyphenols that you don't naturally find in other foods like oleopene and oleocanthal. It's powerfully anti-inflammatory, up there with ibuprofen in some studies.

Dr Angad Dillon: Oh, really?

Dr Rupy: Yeah, yeah, yeah. So they they compared ibuprofen, I think it was a 200 milligram dose versus uh, a tablespoon or so of olive oil and the impact on pain was comparable. It was in specific patients with certain pain though. I can't remember exactly what pain they were suffering with. Um, and we know that it's got cardiovascular benefits as well. It's not particularly high in, you know, long chain omega-3s, but it's got vitamin E and a whole bunch of others. Whether or not it has an impact on constipation, I'm not too sure. But, you know, a Mediterranean diet, I mean, there's so many confounders when you look at all of it. It's very hard to just study an ingredient on its own and look at its impact on uh, constipation. It's usually part of a category of different ingredients. So

Dr Angad Dillon: But you would certainly consider it a super health food, right?

Dr Rupy: I would 100% add a good quality extra virgin olive oil to

Dr Angad Dillon: What what makes an olive oil a good quality olive oil?

Dr Rupy: So we talked about this with Dr Simon Poole on the podcast and there's there's three or four things I always look for. One is uh, early harvest, cold pressed. So early harvest tend to be the higher in polyphenols. And you want to make sure that on the bottle, there's a clear harvest date because over time, just like any fresh fruit or vegetable, it degrades in terms of the nutrient value. Um, you want it mechanically pressed or cold pressed because taking these to high temperatures destroys some of those polyphenols.

Dr Angad Dillon: Early harvest, cold pressed.

Dr Rupy: Yeah. Uh, you want it to be a single origin, so rather than an oil that has been mixed and blended with loads of other oils, all of which have different harvest dates, you know, that way you can ensure that you're getting a good quality product. And the other thing is like uh, about the packaging, so dark glass bottle.

Dr Angad Dillon: So what, UV light interacts with the oil.

Dr Rupy: Yeah, yeah. So it can degrade the oil if it's in a clear bottle. And I tend to go with glass because you don't want something like plastic because the oil, like any oil, will degrade the plastic. We haven't talked about about toxins so much today, but I think that's a whole other, you know, uh,

Dr Angad Dillon: No, I'm sorry to derail you. It's just you introduced me to uh, a good quality olive oil. I absolutely love it. What's it called?

Dr Rupy: Citizens of Soil.

Dr Angad Dillon: Citizens of Soil, amazing stuff, mate.

Dr Rupy: Yeah, I don't have any affiliation with the guys, but it's incredible. It's

Dr Angad Dillon: I don't have any affiliation with them either.

Dr Rupy: It tastes beautiful.

Dr Angad Dillon: And that's all that ticks all your boxes, right?

Dr Rupy: That does, yeah, yeah. They're one of the oils that we actually tested with Simon Poole and he knows them and he's like, yeah, they do a really good quality. But there's so many different oils out there. Like I love getting a variety of from different parts of Europe.

Dr Angad Dillon: They send you a different one every few months, right?

Dr Rupy: Yeah, yeah, it's amazing. Yeah. You get to taste all, one from Spain, one from Greece.

Dr Angad Dillon: Yeah, yeah, yeah. It's amazing.

Dr Rupy: It's an amazing subscription. It's one that you like look forward to.

Dr Angad Dillon: One of your subscriptions I haven't got.

Dr Rupy: Well, we'll get you some Exhale coffee soon as well, mate.

Dr Angad Dillon: Oh, Exhale coffee, yeah. Good for constipation as well.

Dr Rupy: It is good for constipation. But you said if I drink coffee, black coffee on an empty stomach, I'm going to get gastritis.

Dr Angad Dillon: Oh, yes, because caffeine and coffee are notoriously, they have the acids in them. And not only that, they also relax the lower esophageal sphincter. So you are combining an acidic thing with relaxation here, it's notoriously bad for reflux. A lot of my patients with reflux, I ask them how many drinks of, how much coffee do you drink? They're like 10 cups of coffee a day. I'm like, there's your answer. You need to cut that down.

Dr Rupy: But I only have one cup of coffee, so I'm I'm fine, right?

Dr Angad Dillon: Coffee and cigarettes are the bad ones. And those usually go hand in hand. Yeah, yeah, yeah. Especially in young working professionals. Coffee and a cigarette.

Dr Rupy: Coffee and a cigarette. Yeah, yeah, yeah. But at least they're getting outside and getting some sunshine, man. Uh, mate, this has been amazing. Thank you so much, man.

Dr Angad Dillon: I'm glad to be on, mate. And it's rare that I get to have a two hour long conversation with you.

Dr Rupy: I know, yeah. We have to do this more. What else what do you want to talk about next time?

Dr Angad Dillon: Uh, we could have talked about so many things. You get me on about constipation of all topics.

Dr Rupy: But it's important.

Dr Angad Dillon: Fatty liver. Oh, we did talk a bit about bowel cancer though.

Dr Rupy: I would love to talk about fatty liver in a bit more detail because I know that the definition of it, not the definition, the name of it's changed. It's like metabolic steatosis.

Dr Angad Dillon: Associated liver dysfunction. And that's to reflect the fact that it's not just a simple case of fat depositing on your liver. It's the metabolic syndrome, right? It's high blood pressure, diabetes, high cholesterol, abnormal lipids. Super important. Oh, the other thing we didn't talk about.

Dr Rupy: We'll get the podcast listeners to vote as to whether they want you back.

Dr Angad Dillon: There's also um, we didn't talk about GLP-1s.

Dr Rupy: Yes, we should probably just mention that quickly.

Dr Angad Dillon: Okay, go on, go on. Because I have seen a lot of patients who are taking GLP-1s and they're coming to see me with constipation.

Dr Rupy: Yes, yes. Okay, let's okay, so just two lines.

Dr Angad Dillon: GLP-1s, right? They are uh, slowing down gastric emptying. So the classic thing is you take them and you get a lot of nausea, patients have to stop them. But there has to be some kind of issue with gut motility as well because I've had some patients get real bad constipation. And if you're already someone suffering from constipation and you take a GLP-1, it's going to be a bit troublesome.

Dr Rupy: So literally the mechanism of action of these GLP-1s, right? Slowing down gastric emptying.

Dr Angad Dillon: The mechanism is uh, it's um, uh, it's to do with the incretin hormones. And it also has a direct effect on the brain on hunger. Uh, but yes, it slows down uh, gastric emptying. But I don't think that is the, I mean, that's going to contribute to why you're losing weight because you're going to feel fuller quicker. But there are also effects on your um, uh, satiation and your your hunger levels.

Dr Rupy: Yeah, yeah, yeah. I mean, there's there are probably multiple things going on here because these are powerful medications, um, impacting primarily, I think, the appetite hormones, so the incretin hormones, right? But there there is some early research looking at insulin, which is why, you know, it's a it's a really good uh, anti-diabetic medication as well. But just the fact that your appetite is being suppressed, you're less likely to have things like roughage in your diet as well. So there's probably multiple different factors that are impacting why someone presents to you with constipation since uh, starting the drug.

Dr Angad Dillon: Yeah. Just as you mentioned that, there's other things we haven't mentioned now.

Dr Rupy: Yeah, go on. Um, uh, there was um,

Dr Rupy: This is why we need to do for two hours.

Dr Rupy: What did you just say about the roughage and so yeah, so if you're if your appetite is going down.

Dr Angad Dillon: Yeah. So fasting. I I I wanted to ask you this about how things like intermittent fasting, we know that's going to affect your gut microbiome. But I've not really explored this about could intermittent fasting help with um, constipation? And it wouldn't make sense because if you're having your meal say late at night, right? You are going to be filling up your stomach with food and then lying flat going to bed. Um, and that food is not because you're not upright, you're not moving, it's going to sit there, it's going to cause more issues with bloating, indigestion. Could that worsen constipation? Absolutely, I think it could. The other thing I wanted to also mention in the topic of constipation is um, the fact that it why is it slightly more prevalent in women?

Dr Rupy: Yes.

Dr Angad Dillon: And there's been, I think there's been a lack of research on this as with most things in in women's health. Um, women have longer colons, uh, their pelvises are a bit wider, a bit deeper. So longer colons, more looping. But could this be something hormonal going on as well?

Dr Rupy: Yes, yeah, yeah.

Dr Angad Dillon: Progesterone, I think has been shown to reduce colonic motility.

Dr Rupy: So people on progesterone only pills or even just the

Dr Angad Dillon: I don't know. I don't know. We're in speculation mode here, but yeah. But I I do always ask female patients is they notice a trend with constipation and their cycles. I think it's the luteal phase if I'm not mistaken, you might need to fact check that where your progesterone goes up. I could be wrong, sorry. Is it ovulation luteal phase?

Dr Rupy: Follicular phase and then luteal. Yeah.

Dr Angad Dillon: Um, so I always ask, is there a time, have you noticed it in your cycles when you tend to get more constipated? Has there been a change in your bowel habits with different types of contraception, hormonal contraception? It's an under researched area. Yeah, yeah. Which probably warrants a bit more.

Dr Rupy: So do you see, so do you anecdotally even see more women?

Dr Angad Dillon: Anecdotally, yes, I see a lot of young women suffer from bloating. Yeah. When they've had changes in their mood from one hormonal to another.

Dr Rupy: Yeah. We'll have to do a part two, mate. We'll definitely do a part two about some of this stuff. But I I want to talk to you about metabolic syndrome. I want to talk to you about um, fatty liver because that's that's not just getting worse in adults, it's also getting worse in children, right?

Dr Angad Dillon: And yeah, yeah. And weirdly, you can get it in lean people as well.

Dr Rupy: Yes, yeah, yeah, of course. I mean, you like you've got the classic toffee uh, shapes, right? Like a lot of people from um, Asian backgrounds will be lean and have fatty liver. So, yeah, it's a it's a real big issue and I think it speaks to the quality of their diet and how sensitive they are to certain fats and and you know, how many how many calories they're taking in per day. So, mate, this has been amazing. Um, thank you so much. This is like it's going to be really impactful for a lot of people listening to this. Honestly, I really appreciate you doing this.

Dr Angad Dillon: I'm glad to be on, mate. And yeah, I'm very proud of you as well, bro. I mean, look at this. I remember when you first started this was on a on your balcony in Manly Beach. Remember that intro? How did the intro go? Can you remember?

Dr Rupy: It's a little ukulele like, yeah, yeah, yeah. Doctor's Kitchen.

Dr Angad Dillon: Look at this now, mate. It's amazing.

Dr Rupy: I appreciate you, man. Thank you. Thanks, man.