Obesity and the diet-microbiome connection: a conversation with a gastroenterologist [PODCAST]

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What should patients know about diet and its effects on the microbiome? How should primary care clinicians address diet and its effects on the microbiome? What are your tips to address obesity? What are the gastroenterological manifestations of COVID-19?

Supriya Rao is a gastroenterologist.

She shares her story and her expertise in obesity and the diet-microbiome connection.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Supriya Rao. She’s a gastroenterologist and an expert on obesity medicine and the connection between diet and the microbiome. Supriya, welcome to the show.

Supriya Rao: Thank you so much for having me, Kevin. It’s great to be here.

Kevin Pho: So I was wondering if you can start by sharing your story and your journey to where you are today.

Supriya Rao: Sure. Like Kevin mentioned, I’m a gastroenterologist and obesity medicine specialist. After going to college and then doing four years of med school, I found myself drawn to internal medicine, so I ended up doing a residency in internal medicine at the University of Pennsylvania. While I was there, I was trying to determine what to specialize in, or just stay general. I actually really enjoyed my ICU time at Penn, and so I was thinking at some point maybe of doing pulmonary critical care.

But then I also did a few GI rotations and really loved the mentors that I found in GI, specifically one who was really one of those master clinicians and really made you feel excited about learning. After my time with him, I figured, you know what? And actually, people in GI have a pretty good sense of humor, and they seemed kind of laid-back, so that’s why I decided, “You know, let’s try GI.” And I also really like the procedural aspect of it.

So I ended up applying for GI fellowship, matched at Boston Medical Center, and had three years there, which was great. It’s a really great program, especially if you’re interested in doing mainly clinical medicine. While I was there, I learned the ins and outs of the procedural aspects of it and all the different medical issues that come with GI, a wide range of things, ranging from issues with the esophagus, the stomach, the pancreas, the liver, gallbladder, and large and small intestines. So it really spoke to me. It was a broad range of internal medicine, which I still really like to keep up.

Then after I graduated from fellowship in 2014, I went into private practice towards the end of 2014. I work north of Boston, in a town called Lowell and in Chelmsford, not too far from you, and I have been there now for almost six years and really loved it. I was really kind of struggling and grappling with the decision of going into private practice versus academics, which I had been in my entire life. I really felt worried: Am I not going to be able to keep up that high level of academic knowledge and everything?

But the group I joined is a very talented, super academic group. Our whole goal is to bring tertiary care medicine to the community, and so we offer pretty much everything a GI program at a large academic center in Boston would offer. I was able to build up their esophageal motility and GERD program at the hospital from the ground up, which I wouldn’t have been able to do had I gone into a place where it was already existing. And then I also built up more of the motility program.

Then, as time has gone on, and I’m sure you’re seeing this in primary care, Kevin, there are a lot of patients who come in with fatty liver, and their liver enzymes are elevated. I was just telling these patients, “OK, you need to lose weight, diet, exercise.” But obviously that wasn’t really giving them the tools required to actually do something about their weight. And so a couple of years ago I thought, “I really need to be able to give my patients more than just a handout on what a good diet is.”

So I went to Harvard’s Blackburn course in obesity and another few courses, did more CME, and then became board-certified in obesity medicine. There’s a huge intersection with GI and obesity, as there is with endocrine and surgery. There’s a lot of overlap. Obviously, obesity is the root cause of a lot of chronic medical issues that we see in the U.S., and 40 percent of the U.S. population is obese, so it’s definitely a problem that we’re facing head-on as we move forward in medicine.

Kevin Pho: What you said earlier about the diagnosis of fatty liver really strikes a chord with me, because I see so many cases of that. So what kind of advice do you give to these patients, other than eat healthier and lose weight? What’s your approach to obesity for your patients?

Supriya Rao: Right. So when I first see a patient, when they first come in, we kind of sit and talk about if they’ve ever had excess weight issues or been at an unhealthy weight. They’re already self-selecting themselves by coming to me, so they do have some level of motivation to come talk about it, and they don’t feel embarrassed about it or don’t feel worried about it. And so I talk about it. They’re on all these medications, and for a lot of them, their motivation is to get off some of the medications, and they just want to be feeling better. Or their kids are still young, and they want to be able to run after them, keep up with them, and not be tired all the time.

So I kind of want to get behind the motivation as to why they’re doing this. If it’s obviously to fit into some X number of size, that’s a goal in itself, but I want to kind of push further and really understand why they’re doing it. Because for me, I don’t care about people looking like models and stuff. I’m caring more about their chronic medical issues and being able to prevent those as time goes on, and to be able to get people off their medications.

And so I talk about what their diet is like. What exactly are they eating? Can they give me a 24-hour recall, a two-week recall of what exactly they’re eating during the day and what times they’re eating? Do they eat for emotional reasons? Is there any behavioral aspect to their eating? What kind of activity do they do? How good is their sleep?

Sleep is so important because it’s one of those things that people still really discount as being important. They don’t think that proper sleep is something to be concerned about. But as we know, if you get less than seven to eight hours of sleep, you’re really going to set yourself up for more chronic medical conditions, including heart disease and sleep apnea. All these issues kind of rear their ugly head. I feel like you can do everything perfectly, but if you’re not getting a certain amount of sleep, it’s not really going to work. Certain hormones get upregulated, because our body thinks we’re in a constant state of stress if we don’t get enough sleep.

And so we talk about sleep hygiene, and we talk about stress management. It’s kind of like a full lifestyle discussion about what exactly they’re doing, and then we kind of start tackling each one, one by one, and what improvements we can make.

Kevin Pho: You’re also an expert in the connection between diet and the microbiome. Now, why is that connection important for patients?

Supriya Rao: With the microbiome, there’s still a lot that we don’t know about it. Obviously, there’s been a ton of research, but there’s still quite a bit we don’t know. The microbiome is basically this ecosystem that resides in our small intestine and our colon, and it’s about hundreds and trillions and trillions of bacteria that are present, anywhere from 1,000-1,200 different species of bacteria. It’s really important in vitamin synthesis, fermentation of carbohydrates, and maturation of the immune system.

Our microbiome starts to be determined from when we’re young, and if we don’t treat it well, it can possibly lead to issues with chronic medical problems later on, specifically autoimmune diseases like celiac disease, or IBD, like ulcerative colitis or Crohn’s disease. So having a healthy microbiome is super important just for our overall health and chronic medical conditions.

If you are eating a diet that’s high in saturated fat, high in processed meats, high in animal products, and low in fiber, your microbiome is not going to be very diverse. It’s not going to be treating you well. You’re going to have issues with gut motility. That’s why the American Cancer Society just came out with their guidelines a couple of weeks ago about what your diet should be, and it’s becoming more frequently seen. The Mediterranean diet and the Blue Zones also kind of promote a plant-based, overly a plant-based diet: high diversity in fruits and vegetables, whole grains, low amounts of animal products, and good social support. All of these things are really important in ensuring a healthy gut microbiome.

And so with your microbiome being healthy, your body will be happy, and your motility will work properly. There are a lot of things that are kind of predicated upon a healthy microbiome.

Kevin Pho: From a primary care standpoint, is this something that we should screen for? What are some tips that you can share with your primary care colleagues?

Supriya Rao: I know it’s hard in primary care, because there are so many things that you guys have to really think about and make sure that the patient is doing already. So I would say just have a quick discussion, especially if you notice that they’re at an unhealthy weight. Just have an initial discussion with them about it, because I think a lot of people don’t even broach that topic because they’re too scared.

But we need to treat obesity as a chronic medical disease or chronic condition and not something that, unfortunately, is tied to a cosmetic thing, and so people are so nervous about talking about it. But it’s a disease, just like high blood pressure, diabetes, and high cholesterol. It’s similar in that sense, and we have to treat it as such. And so we need to broach the topic with patients and really understand. In the United States, only 3 percent of the population truly gets the amount of fiber that they should be eating. So I would say to primary care: Try to encourage people to increase the amount of fiber in their diet from food sources. Taking dietary supplements is one thing, but if they can increase the amount of fiber from their food itself, you’re going to be much healthier.

Kevin Pho: And what is the role of probiotics in all of this?

Supriya Rao: So probiotics are a multibillion-dollar industry, and for a long time people, and even today, people think, “Oh, they’re going to help me. They’re going to help kill the bad bacteria and populate the good bacteria.” The problem is that there’s not great evidence to back probiotics necessarily. In certain cases, they are helpful, so if you have ulcerative colitis or pouchitis, they can be helpful in those conditions. Also, sometimes I’ll have my patients be on a probiotic for a post-infectious IBS syndrome. But in general, they’re not that helpful.

It’s much better, actually, to eat prebiotic foods, which are foods that are high in fiber. What happens with prebiotics is that those fiber foods come into your gut, and the bacteria in your gut ferment that fiber into short-chain fatty acids. That leads to increased resilience in the gut microbiome and improves its overall health. So I would say, more important than taking a probiotic supplement, eat foods that are high in prebiotics, so things like leafy greens, leeks, kale, like leafy greens, onions, garlic, and lots of different fruits, which are high in prebiotics. So that fiber is super important.

And also probiotic food: If you eat fermented foods like kimchi, sourdough bread, kombucha, and sauerkraut, all of those are actually much better to eat than, I would say, around the middle probiotic supplement.

Kevin Pho: Regarding that connection between diet and the microbiome, at what point do we refer out for consultation with a gastroenterologist like yourself?

Supriya Rao: I would say if a patient is having symptoms like bloating and just overall changes in bowel habits, you can try some of these things. Actually, for a lot of patients, I tell them to stop dairy, because as a species, in general, we are lactose intolerant, and those who have evolved to be able to handle dairy more are actually, I guess, quote-unquote mutants. But overall, large amounts of dairy aren’t great, and as a society we do eat a lot of dairy. So for primary care, try cutting out dairy for a few weeks and see how patients feel. But if they still have persistent symptoms beyond that, and you’ve tested them for celiac disease or small bowel bacterial overgrowth, then at that point I would refer out for possible endoscopic procedures or any further workup.

Kevin Pho: Now, to switch topics, we’re speaking in the first week of July, and COVID-19 is flaring up in parts of the country like the South and West. Can you share some of the GI manifestations of coronavirus that we should look out for?

Supriya Rao: Sure. In China, there have been some studies of GI manifestations, even without respiratory symptoms at all. The main one is diarrhea, and actually, I think the CDC and the WHO have put it as one of the main symptoms for COVID. So diarrhea, nausea, vomiting, and loss of appetite are all possible signs or symptoms of COVID. The problem is they’re super nonspecific. If someone doesn’t have respiratory symptoms and they have the GI symptoms, they may not seek attention as fast as someone who has shortness of breath, because they may think it’s maybe food poisoning or something else.

So you definitely need to keep diarrhea on your kind of list, just because sometimes delay in care happens, because we’re not going to the emergency room or seeing your physician as quickly. It’s really hard, because with patients with IBS or patients with Crohn’s or colitis, it’s really difficult to kind of tease out: Is it COVID? Is this IBS? Is this IBD? So make sure you speak with your primary care or your gastroenterologist about it.

There have been some endoscopic findings with COVID in patients with rectal bleeding, and they find that there’s hemorrhagic colitis or segmental colitis, esophagitis, or gastric ulcers, which may speak to kind of the dramatic nature of COVID causing kind of ischemic colitis. There are definitely a lot of GI manifestations.

Kevin Pho: We’re talking to Supriya Rao. She’s a gastroenterologist in northern Massachusetts. What’s your take-home message for the KevinMD audience?

Supriya Rao: I guess my take-home message is, in this era of COVID, everyone’s trying to be healthier. Everyone’s trying to do the right thing for themselves. I think as long as you are paying attention to what you’re eating, your sleep, your mental health, all of these different aspects, as much as you can, whatever you can, I know it’s a very stressful time, but whatever you can do to pay attention to those aspects of your life and try to improve upon those, you’re going to see it pay out in spades as time goes on.

Kevin Pho: Well, thank you so much for your expertise and insight, and thank you so much for being on the show.

Supriya Rao: Thanks for having me, Kevin. It was great to be on.

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