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Unknown Speaker  0:04
Welcome to the physicians guide to doctoring Episode Three, what every doctor should know about gi issues. We’re interview Dr. Daniel Marino, gastroenterologist at the University of Rochester and currently the fellowship director about things that every doctor should know about gastroenterology. And when I say every doctor, I mean, like myself and otolaryngologist, a pathologist, radiation oncologist, what are gi issues that every doctor should be familiar with? We talk about the fun stuff. Diarrhea, went to be worried about it wouldn’t be less worried about it.
Unknown Speaker  0:44
GIP
Unknown Speaker  0:46
when is that potentially a catastrophe. And when can you wait a couple days before really starting to worry. What’s up with gluten? We get an interesting take on gluten from the gastro Just add some fun cocktail party facts about the GI tract. It was a fun conversation. I enjoyed it, and I know you will. Welcome to Episode Three of the physicians guide to doctoring. This episode is about gastroenterology. We have one of my
Unknown Speaker  1:22
good friends from medical school Danielle Marina. Danielle, thank you for being with us today.
Unknown Speaker  1:27
Thank you for having me bread.
Unknown Speaker  1:29
So Danielle and I were at SUNY Buffalo together. And then after we graduated, where do you go?
Unknown Speaker  1:37
I did my internal medicine residency at Yale in New Haven, Connecticut. And then I started fellowship at the University of Rochester. And I stayed on there as faculty. So right now I’m an assistant professor of medicine there, and I’m the GI Fellowship Program Director.
Unknown Speaker  1:55
Fantastic. Look at what you’ve done with yourself. So That definitely gives you a lot of street cred when talking about all things gastroenterology. And so today’s show, we’re just going to be talking about everyday facts that the general population should know about gi. But more specifically, doctors should know because, you know, we’ve all had situations where one of our neighbors asks us for advice, and you might be a pathologist, and you don’t know anything about gastroenterology except for one or two clinical rotations that occurred five or 20 years ago. And so, you know, you’re expected to know things because you’re a doctor, but they may be completely outside of your specialty. So, so today, Danielle, I want to talk to you about some things that that that both of us think that just the every doctor should be somewhat familiar with. As a disclaimer, Danielle is employed by the University of Rochester and I’m a partner at NT and allergies. So associates, both of us are currently representing ourselves and other organizations. And so anything that you hear does not represent the views of those organizations, but are solely of our ourselves. That being said, we’re also going to be talking about some clinical information and we can bear no responsibility for outcomes that occur based on advice that you take here. So as the radiologist like to say, clinical correlations are recommended. So, so Danielle, let’s start off talking about one of my favorite
Unknown Speaker  3:38
activities against one of my favorite pathologies, diarrhea.
Unknown Speaker  3:45
All right. So this this should be a fun one. So So one thing is, let’s say the scenario that I have before my my neighbor is mowing his lawn and has to keep running inside Because he has very bad diarrhea. So he sees me blowing my lawn and says, Wait a second. You’re a doctor. Let me tell you about my diarrhea. Mm hmm. Yeah.
Unknown Speaker  4:14
Yeah, that happens to me regularly.
Unknown Speaker  4:17
I would imagine, but hopefully those of your patients and not your neighbors,
Unknown Speaker  4:21
sometimes the mail lady, okay.
Unknown Speaker  4:24
Okay. I guess she sees those offers for a job in the Midwest by Lake an hour and a half. Exactly. And she knows that you’re being offered gastroenterology, so she kind of figured it out and can now ask you, she’s carte blanche to ask you for advice. And you have to give it to her otherwise you’ll get your mail. So, okay, so diarrhea. So, so I want to break this down into to two things. Really, when is it time to worry? What are we looking Four. So what are the important questions that we want to ask said, neighbor? And what are the potential catastrophes? But what are the horses? Right? What are the things that that it probably is? So first, what are the red flag questions that you’re going to ask to make sure that it’s not some potential catastrophe?
Unknown Speaker  5:18
And say the main thing is like, is there blood in the diary? So if it’s bloody diarrhea, it’s probably something serious, it could be an infection. But if it lasts for more than a week or so then it’s probably something more than just an infection. So, if there’s blood in it is probably the first question I would ask. If there is, you know, I’m thinking something like inflammatory bowel disease like ulcerative colitis or Crohn’s disease, maybe even something like colon cancer. So, those are bad. Then you want to ask like, Are you having nocturnal diarrhea, so usually, you know it’s normal that people have bowel movements, usually first thing in the morning or after eating. And that’s because we have something called the gastro colic reflex when your stomach descends with food, it leads to parasitosis of the colon and you dedicate and but if you have some sort of pathology going on that may have you have diarrhea even at night. So usually if it’s at night, that’s something organic going on, again, like inflammatory bowel disease. Things like irritable bowel syndrome, which is super common and probably the most likely thing causing diarrhea and most people, people wouldn’t be waking up in the middle of the night have bowel movements. So nocturnal diarrhea is definitely a red flag. blood in the stool and then I’d say you know if it’s going on for a long time, and it’s not a beating. If there’s any weight loss or signs or symptoms of dehydration, like lightheadedness, dizziness, palpitations, Or any other kind of symptoms that go along with it like vomiting or severe abdominal pain, those are all kind of things that mean that your neighbor should probably go see a doctor and not just talk to you while he’s smelling.
Unknown Speaker  7:14
So, so what but what can we use to differentiate an ER visit from an hour waiting for an outpatient appointment? So clearly dehydration, if you’re showing signs of dehydration, you can’t make an appointment for doctor that may occur in a couple of weeks. Right clearly, that’s that’s an emergent issue. So if there’s, if there is, are there signs of dehydration, go to the ER, if there’s blood in the stool. So we have we’ve talked about this before just to take a little aside.
Unknown Speaker  7:47
Should they have a Hema called test?
Unknown Speaker  7:51
Oh, Jesus, no. So a Hema cult test is called that for a reason. It’s looking for a cult blood, meaning blood You can see. So I mean, if it’s frankly bloody, you don’t need to do a Himachal, we know that it’s bloody. So if someone’s complaining of bloody stool, that doesn’t necessarily mean they need to go to the emergency room. I mean, it kind of depends on the situation if it’s a copious amount of blood or if it’s just rectal bleeding without diarrhea, per se, yeah, that’s probably warranting an emergency room visit. But if it’s a little bit of blood mixed in with your diarrhea and it’s been going on a bit, see a doctor as long as you don’t have you know, signs and symptoms of significant anemia or dehydration, you don’t have to go to the emergency room.
Unknown Speaker  8:37
So anemia dehydration, which can have similar symptoms, those would be reasons to go to the ER otherwise, you know, just get to your at least your internist if not a GI doctor pretty pretty quickly. Okay. Fantastic. So you also mentioned GI gi pain, with with the diarrhea, let’s say the let’s say he’s mon as long And he’s he’s, he’s a little slow because he’s got a stomach ache. So he doesn’t have diarrhea, doesn’t have nausea, vomiting. It’s just stomach pain. So, you know, acute stomach pain, chronic stomach pain. Well, let’s let’s talk about acute, really, first. When when is this an ER visit versus an outpatient visit?
Unknown Speaker  9:25
I’d say, you know, there’s a million things that can cause acute abdominal pain, but I think if it’s someone that doesn’t normally have abdominal pain, and they have severe abdominal pain, there’s a lot of serious things that could be happening. So if this is a person that has no gi symptoms normally and all of a sudden has severe abdominal pain, no matter where it is, they really should go to the emergency room. It could be something serious like coli cystitis or colon Titus, diverticulitis, and abdominal perforation from for some reason, you know, perforated peptic ulcer or perforated colon, mesospheric ischemia. So there’s a lot of like serious things that could turn into like a surgical emergency if ignored with acute onset of severe pain. That being said, you know, there are a lot of people that have actually like chronic abdominal discomfort and people who have irritable bowel or some what we call like functional abdominal pain, which is more of like a nerve related issue. And those people who have kind of chronic abdominal pain may have acute bouts of and they don’t necessarily mean to go to the emergency room every time I think, you know, we need to take it in context of what the baseline is and things like that and where the pain is and if it’s related to deprecation and such.
Unknown Speaker  10:48
So clinical correlation recommended
Unknown Speaker  10:50
absolutely, always.
Unknown Speaker  10:53
Disclaimer, right. So he’s saying, This is the worst stomach pain of his life, he should probably go to the ER But if he says, but it’s pretty similar to the stomach pain I had yesterday and the day before and the last few weeks in the last few months, that speaks to the lack of lack of urgency, because there seems to be.
Unknown Speaker  11:10
Yeah, and we’ve all seen the patients who claim they have 10 out of 10 or 12, out of 10 pain as their, you know, on Facebook role. So, like, you know, you kind of have to take it with a grain of salt and see what, you know, if they’ve had it before, and things like that. But
Unknown Speaker  11:27
I actually have a personal aside about my own gi pain, because I have you on the phone. So free comes to take advantage of the opportunity. Yeah, Indeed, indeed. It’s actually it’s not a concept. It’s just I think it’s an interesting story. So my wife and I were on our honeymoon, which was a safari in Tanzania. So we were on the flight back. And it was it was amazing as we were on the flight back and I started to get some stomach pain. And it was pretty bad, pretty bad. And it would happen After I got back every time I ate, and I was just I just stopped eating because it was so severe. And I thought it was constipation. So I just tried treating myself with some over the counter stuff and you know, nothing was working. And ultimately, I saw gi I hadn’t Ed, everything was fine. Here’s what it was. She was pregnant with our first child. And this is apparently a phenomenon. This is not unheard of for for like anxiety and I’m sure you see this anxiety related abdominal pain, and it had nothing to do with a trip to Africa, or having eaten something I didn’t have God. It was just because I was anxious because he was pregnant with our first kid. So
Unknown Speaker  12:49
So I as I like to say the GI tract is the window to the soul. So whatever
Unknown Speaker  12:58
feeling on the inside, usually presented itself with, you know, some gi distress, or, you know, they say butterflies in the stomach, you know, all those things are related to kind of what’s going on in your life. Stress definitely affects the GI tract significantly. And that’s because there’s almost as much nerves in the GI tract as there are in the spinal cord.
Unknown Speaker  13:21
And really, Mm hmm.
Unknown Speaker  13:24
There’s like a ton of nerves and neurotransmitters and it’s really complicated between the brain and the gut connection, but definitely they both interact with each other. So stress can cause gi symptoms and gi symptoms can cause severe stress or anxiety or depression or, you know, other neurological symptoms. So it’s pretty interesting. Yeah, and it’s hard to sometimes it’s hard to tease out, you know, what’s an organic, you know, structural problem versus more of a nerve related issue.
Unknown Speaker  13:57
Yeah, that’s probably one of the things that’s more challenging. For you to figure out when you’re doing your outpatient console, isn’t it?
Unknown Speaker  14:04
Absolutely. Definitely, history is like huge. It’s all about taking a really good history. And sometimes, you know, patients aren’t really able to give you a good history. So sometimes it’s difficult. You have to do you know, some tests that maybe you didn’t necessarily want to do, but you have to roll something out.
Unknown Speaker  14:22
Sounds like that is the post nasal drip of otolaryngology,
Unknown Speaker  14:26
I can imagine, or LPR
Unknown Speaker  14:29
or or LPA. Well, that’s the those two things are intertwined. This like mucus sensation in your throat when they have normal nasal exam and laryngeal exam and everything and all this throat clearing and that can be very, very challenging to figure out. So I guess we all have our own. Every specialty has their own post nasal drip. Yep. So that was interesting what you said about the number of nerve endings in the GI tract. So it was Something else that we wanted to talk about? What are some other cocktail party facts that you might be able to share with our listeners? is there is there anything else that you even if you might find it interesting for you, and you might think it’s boring to us. I doubt that I think I’m gonna find it interesting.
Unknown Speaker  15:20
Well, um, okay, one thing that people don’t realize is that like, there’s no set definition of like diarrhea or constipation. So like, it really just depends on the patient. And the variation of normal is pretty big. So we consider normal anything from like, one bowel movement every three days to up to about three bowel movements today.
Unknown Speaker  15:46
The rule of threes, the poop, the poop rule of threes,
Unknown Speaker  15:50
so race, so every area
Unknown Speaker  15:53
or every three days, all normal,
Unknown Speaker  15:57
but even I mean, that’s kind of wishy washy. Because if someone tells me Well, you know, my whole life I’ve had four bowel movements today and that’s just been me my whole entire life then that’s probably normal for them. And I’m not overly worried about it, especially if it’s not bothersome to them.
Unknown Speaker  16:14
I think it’d be hard to hold down many jobs with
Unknown Speaker  16:22
Yeah, that’s gonna, my patients would get pretty upset. really willing again, cuz he’s, again,
Unknown Speaker  16:30
really well that’s, that’s something that I find interesting. You know, some people take about 30 seconds to have a bowel movement. And for some reason, it seems many men take like three hours. I kind of think you use it as an excuse to like hide away in the bathroom with your phone and like, fall down a rabbit hole in the internet or something shouldn’t have to take that long.
Unknown Speaker  16:56
Listen, those those patients then end up getting hemorrhoids. True keep keep colorectal surgeons in business.
Unknown Speaker  17:05
Oh, here’s a fun fact.
Unknown Speaker  17:08
So you don’t have that may or may not include me.
Unknown Speaker  17:12
So you know how we sit in this country we sit on a toilet to go to the bathroom. I know, Brad, you’ve done a lot of traveling. And you see like in other countries, people don’t necessarily sit on the toilet like they’ll swap
Unknown Speaker  17:25
down toilets. Yep,
Unknown Speaker  17:26
yep. And so that’s actually the best way to dedicate because it opens up the anal rectal angle. There’s a muscle that kind of as a sling muscle and pulls on like the rectum. It’s called the pubic talus. And when you when you squat down, that actually opens up the pubic talus muscle and opens up that angle so the poop can come out easier.
Unknown Speaker  17:49
I would also imagine that you’re because you’re folded up like an accordion. You’re also squeezing things a lot more.
Unknown Speaker  17:56
Yep. And it helps your abdominal muscles, musculature, you know work better than if you’re Kind of stretched out. And
Unknown Speaker  18:03
this is why have you seen the Squaddie party?
Unknown Speaker  18:06
Yes, but the like the weird unicorn
Unknown Speaker  18:09
rainbow ice cream? Yeah.
Unknown Speaker  18:12
We didn’t do any disclaimers at the beginning. are you receiving any compensation from the squad?
Unknown Speaker  18:16
I have no financial
Unknown Speaker  18:18
disclosure. So I’ve made financial disclosure.
Unknown Speaker  18:21
I am a big fan of the squatting money because that is the correct way to put their right. So I do recommend that to my patients a lot and it avoids straining and kind of prevents you from developing Hemorrhoids and it makes a really good Christmas present. I have given it to many people
Unknown Speaker  18:38
really.
Unknown Speaker  18:40
That’s funny because we give for for newborns we always give the snot sucker. Oh God,
Unknown Speaker  18:45
that thing freaks me out.
Unknown Speaker  18:50
Like gifts that are related to what we do. specialties.
Unknown Speaker  18:54
Yeah, well, we realized we find it useful. OK, so the Squaddie party seems a good alternative to standing on your toilet seat and then squatting down.
Unknown Speaker  19:06
I have had a pinch tell me that they do that though. Like, just casually mentioned. Oh yeah, my whole life I just put my feet on the toilet seat. Now was
Unknown Speaker  19:13
that person born in a country where that is a routine? Oh, no. It was a good idea.
Unknown Speaker  19:20
She actually I think she she has a definite contrary disorder. She has a problem where her you know sphincter doesn’t relax and she kind of figured it out realized that without knowing exactly what it was and kind of worked around it on her own and never talked to any doctors about it.
Unknown Speaker  19:34
So some people self treat things like anxiety with marijuana and she self treats her erectile dysfunction by squatting. Yeah, well that’s that’s I have to say that is pretty impressive. That she was figure that out and had just been doing it her whole life.
Unknown Speaker  19:54
And when and when the patient told us that like when I went back in the room with the fellow the fellow is Pretty like shocked that the patient made her own diagnosis. Yeah, that’s like okay, we know what the problem is. Thanks.
Unknown Speaker  20:09
So, fun facts one
Unknown Speaker  20:11
fact. So I have a question. Just things that can turn your poop. Different colors, not not pathologies, right? Like remember there’s something that causes khaki colored poop, right?
Unknown Speaker  20:22
Oh, yeah. Well like clay clay colored. Yeah, that’s when you have like a billionaire obstruction. gonna lose the Bible because the Bible is what makes your poop brown makes it because if you lose your Bible, you can have like a white. Sorry.
Unknown Speaker  20:46
biliary obstruction.
Unknown Speaker  20:49
She knows now, biliary obstruction.
Unknown Speaker  20:55
What about stuff that you can
Unknown Speaker  20:59
that you can eat that We’ll turn your different colors.
Unknown Speaker  21:03
So beats concerned your poop red. Okay? I do not like beets thankfully but beats continue to poop red pepto abysmal concern or poop black and a lot of I can’t tell you how many times like we’ve been consulted for melanoma, which is you know black stool it’s supposed to mean an upper gi bleed. But really it just turned out the patient was eating a bunch of pepto abysmal and so that’s why it was black iron pills can also turn your stool black.
Unknown Speaker  21:32
Well, hence the need for a humid cold right because then because that’s not Frank. That’s like water not like what about the patient right? Like, then you’re doing a Hema Colton someone because you can’t tell if it’s blood or beats.
Unknown Speaker  21:46
So you can kind of tell the difference, actually, yeah, it’s red, but it’s like, it’s like a weird red. It’s not like a blood. Right?
Unknown Speaker  21:53
That’s, that’s what I tell my patients about tonsillectomy. So one of the things that you read on the internet after tonsillectomies, don’t drink anything, Read because you won’t be able to tell the difference. If you’re if you’re bleeding, which is a common problem after tonsillectomy, you won’t be able to tell your if you’re bleeding or if it’s Hawaiian Punch. And so what I tell my patients is one of the risks is dehydration. So if all you can get your kid to drink is red Gatorade or Slurpee or Hawaiian Punch, like we can tell the difference between Hawaiian Punch and just get them keep them hydrated. Absolutely. Those those misconceptions start.
Unknown Speaker  22:29
Yeah, so have you ever smelled melanoma? I’m sure you. I mean, people know like, you can tell the difference between that at this point.
Unknown Speaker  22:38
I’ve been doing total laryngology for, you know, four years in residency and seven years and so 11 years. So if I’ve smelled Melanie, it was over 11 years ago, but I you know, I can still remember it.
Unknown Speaker  22:51
It’s one of those things. Yeah, don’t forget. Yeah,
Unknown Speaker  22:53
it’s one of those things. I remember hearing in a lecture in medical school. Yeah, their poop really smells bad. Everybody’s poop. Oh, wow. Yeah, Melanie, okay. Yeah, no, that is a whole different level. So you don’t really need to just remember cold because oh my god that is room clearing. Yeah.
Unknown Speaker  23:11
Right? And Hema cold. So Hema calls is actually made for colorectal cancer screening, there’s really no indication to use it otherwise, it’s not to look to see if someone’s bleeding because it can have a lot of false positives, you know, someone has Hemorrhoids and they can have a
Unknown Speaker  23:28
positive from sitting on the toilet for three hours at a time absolutely going down or you know, rabbit hole,
Unknown Speaker  23:36
and especially getting like a rectal exam and then doing the chemicals. That’s like a huge show. Now, even just putting your finger in can cause some minor, you know, trauma that can cause the chemical to be positive. So if someone’s gi bleeding, like will know, like, you know, you check the credits. Blood is a laxative. So if they’re actually gi bleeding, they’re going to be going frequently. They’re not going to Just have like one bowel movement a day or whatever their normal. So like builds a clear themselves. We don’t need the chemicals, it’s not going to help us. Stop doing him and GM and chemical positive is not a color. So we always ask what colors is still and they’ll say positive. I’ve never seen that on a crayon.
Unknown Speaker  24:20
It’s like red, brown or black. Like that’s what we care
Unknown Speaker  24:24
or khaki, I meant Klay
Unknown Speaker  24:29
whatever fun facts Oh. So your colon actually sees like 10 liters of fluid every day. And it’s like really good at absorbing water. So it absorbs like nine liters of fluid every single day. That I don’t know. I find that to be a fun fact that is.
Unknown Speaker  24:48
I’ll supplement that fact with another fact. You generate a leader to a leader and a half of mucus a day between your nose and your mouth and that gets swallowed. That’s a lot. That’s a lot. So yeah, grow. That’s the whole post nasal drip and people like but I feel this mucus dripping down the back of my throat. Yes, it’s called us I know it’s called sorry mucus, ciliary flow, the sinuses and the nose make mucus it’s pushed post yearly, by the cilia purpose and on purpose in a very intentional way in a very specific way. Actually, you can, if things go off course, you can end up with something called recirculating mucus and that can be a night as for a sinus infection, so it ends up getting swept back post here early and then you swallow it. So all of that mucus is supposed to is post nasal drip so it is in fact,
Unknown Speaker  25:40
normal.
Unknown Speaker  25:42
Now it can be abnormal in the same way that you were you were saying about the GI tract right like if you absorb a little too or I guess a little too much like if you’re dehydrated, right like you take a little too much water out of your still you’re going to get constipated, very hard to lose are a little too late. Just a little bit too little. And then the end of the diarrhea, you know, people are very sensitive to the sensation of mucus dripping down the back of their throat, so a little little too much in a cold and it can really bother you. Or, if your mouth is really dry, you end up with this very viscous mucus and people end up spitting and thinking that they’re making too much mucus, but really, it’s just their throat is dry. So it’s a little little otolaryngology aside for you. So just another aside, please stay tuned, because Dr. Marina will be back with another episode if you’re enjoying this one. And I hope you are because I certainly am. About more more fun and interesting gi facts, but we’ll get a little more technical in the next one. And we’ll talk about reflux and we’ll talk about other other workshops. It may get controversial, and it will certainly get exciting. But for this episode, I wanted to talk a little about gluten. Yeah, we’re going to be a little controversial now. So So Not good, not not celiac specific Because that is a my understanding it is a pathology based diagnosis, right?
Unknown Speaker  27:07
Absolutely. You need to have to auto biopsies showing vilest blunting to make a diagnosis of celiac.
Unknown Speaker  27:14
Okay. But what about all of those other patients who complain about gluten sensitivity? And are celiac negative and just to be clear, gluten is a protein that’s present in wheat. And it’s what gives dough its stickiness and in doing this
Unknown Speaker  27:39
so, for the bait Baker side of me, there you go.
Unknown Speaker  27:43
Nice. So, um, yeah, so there are a lot of people that are sensitive or intolerant to gluten but don’t necessarily have celiac. And that’s because, you know, we’re not really made to digest gluten all that much and we end up to and way more than we can handle. And so actually most people would probably feel pretty good on a gluten free diet. It’s hard to do. But gluten is one of those things that gets fermented in the GI tract, and can cause a lot of gas and bloating and discomfort. And so there’s a ton of people that just, you know, have symptoms with gluten. But it’s actually really important to tell the difference between celiac and just gluten intolerance or gluten sensitivity. Because people with celiac, you know, there’s actual damage happening to the small intestinal lining, that can lead to a lot of other problems like osteoporosis. The chronic inflammation in the gut can lead to things like small bowel adenocarcinoma or small bowel lymphoma. And so it’s really important to kind of Make the diagnosis does this person actually have celiac disease? Or can they just not tolerate gluten? And that needs to be done before they go on a gluten free diet. So a lot of times primary care doctors will have their patients go on a gluten free diet or or patients themselves or their read on the internet and they’ll go on a gluten free diet and they feel so much better and then it’s really kind of hard to convince them Well, okay, go back on. So we can
Unknown Speaker  29:26
have this loaf of bread, right? That’s gonna make
Unknown Speaker  29:31
me uncomfortable, right and so we can take a piece of so we can put you through a procedure where we actually take a piece of you and give it to some other guy to look at under slide.
Unknown Speaker  29:41
Right. It’s it’s really hard to convince people to do such things but it is important to know the difference and then plus it has you know, implications for families because it is hereditary. So, if patients do have celiac then we would recommend getting their kids tested and stuff. So it is important to kind of sort that out. But yeah, lots of people just, you know, don’t feel too good on gluten club cause bloating, abdominal discomfort, diarrhea, gas sounds
Unknown Speaker  30:10
a lot like lactose intolerance, right? Like we haven’t evolved to consume the amount of dairy products that we do in our modern society. And so this is our body telling us that you know what, a little bit good for you fine. Keep the you know, vitamin A and D levels up but
Unknown Speaker  30:34
the volume that you’re eating? Yeah, I’m sorry. I’m sorry, saying
Unknown Speaker  30:38
you can overwhelm your lactase, you know, the enzyme on your small bowel Villa that kind of break down the lactose. And actually, as we age, the lactase goes away. So, like for certain, like European.
Unknown Speaker  30:57
derive, derived, I guess European ancestry
Unknown Speaker  31:01
said yes descent Thank you.
Unknown Speaker  31:05
There’s a very high rate of lactose intolerance like as we as you age, so by the time you’re like in your 70s I think it’s like something like 60 to 70% of like Eastern European Caucasians will have lactose intolerance. So it’s very common as we get older.
Unknown Speaker  31:20
Hmm. And can you up regulate it? Like by fighting the good fight and just kind of pushing through
Unknown Speaker  31:26
just pushing through and eating more and more cheese?
Unknown Speaker  31:31
No, no, no.
Unknown Speaker  31:34
Yes, unfortunate.
Unknown Speaker  31:35
It is. It is because I love a good
Unknown Speaker  31:38
cheese. Yeah, but fortunately, I have not yet developed lactose
Unknown Speaker  31:42
intolerance that will be associated cheeses are some of the best. My wife is Swiss. So we every so often, we’ll have a good stinky cheese. It smells like feet, but it’s delicious.
Unknown Speaker  31:56
Yeah, so the the good thing though, is that there’s like a ton of gluten free products out there and they don’t taste that bad. So, you know, for the people that it does bother are the people with celiac, there are good options now, whereas like a decade ago, people were it was hard. There were
Unknown Speaker  32:10
no yeah. Yeah. I mean, there’s restaurant menus and yeah, it’s hopefully for the lactose intolerant community. There will be a similar revolution. But
Unknown Speaker  32:27
you can just take
Unknown Speaker  32:29
you can do that. Well, Danielle, this has been Dr. Marina. This has been very informative. Thank you very much for your time. I appreciate it. It was a lot of fun. I can’t wait to have you back for future episodes.
Unknown Speaker  32:44
Cool. Thanks for having me brand.
Unknown Speaker  32:51
This was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher or wherever you get your podcasts and register review. If you have something nice to say. You can also visit us on Facebook search physicians guide to doctor
Transcribed by https://otter.ai