EPISODE 18: LIVE DIRTY AND EAT CLEAN

Featuring: Dr. Robynne Chutkan

 

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The Engine 2 Team is on-site at the 2019 Plant-Stock this week, so we’re bringing you a special edition of the podcast featuring a live presentation directly from the stage of 2018 Plant-Stock featuring Dr. Robynne Chutkan.

Our microbiome is next frontier in health and vitality and Dr. Chutkan’s no holds barred lecture entitled “Guts, Germs, and Stools” will educate and encourage you to Live Dirty and Eat Clean.

Robynne Chutkan, MD, FASGE

Robynne Chutkan, MD, FASGE

Dr. Robynne Chutkan is an integrative gastroenterologist and the author of Gutbliss, The Microbiome Solution, and The Bloat Cure. Educated at Yale and Columbia, she’s been on the faculty at Georgetown University Hospital since 1997 and is the founder of the Digestive Center for Wellness, an integrative gastroenterology practice incorporating microbiome analysis and optimization, nutritional counseling, and biofeedback as part of the therapeutic approach to digestive disorders. An avid runner, snowboarder, and yogi, she is passionate about helping her patients live not just longer lives, but dirtier ones!

Dr. Robynne Chutkan Website

Dr. Chutkan’s Books


Rip Esselstyn: Hey guys. I love hearing how many of you are now making your own plant based milks at home using The NutraMilk. As you know, we fell in love with this blender while making our first batch of oat milk. And again, it just takes two minutes and there's no need to strain. What more could you ask for it when it comes to making your own plant based milks? We are now so confident, that we are experimenting with other plant based milks because it's so easy. Last week, we made a combination of almond and flax milk that turned out amazing. And we've also been saving vegetable scraps to make our own vegetable broth as well. I can't recommend this appliance enough. Visit thenutramilk.com. Use the code Plant-Strong for free shipping and a $50 discount.

Rip Esselstyn: Hello, Plant-Strong people. I have a treat for you today. I am really excited. I'm still in Black Mountain, North Carolina. Wrapping up our Ninth annual Camp Plant-Stock event. So this will be a departure from our regularly scheduled programming. Last year, I was blown away by this talk at our 2018 Plant-Stock by Dr. Robynne Chutkan. She is an integrative gastroenterologist, say that five times quick. She's also the bestselling author of the Microbiome Solution and the founder of gutbliss.com. She was educated at Yale University and Columbia. She's been on the faculty at Georgetown University since 1997, and is the founder of the Digestive Center for Wellness. She is absolutely brilliant. She is Plant-Strong. She is passionate about helping your patients not just live longer lives, but dirtier ones. Her motto is, "Live dirty, eat clean." That is something that I can definitely get behind. Here she is with her no holds barred lecture entitled Guts, Germs, and Stools. Let's cut to the stage and learn how our microbiome is the next frontier in health and vitality. Let's roll Robynne.

Robynne Chutkan: So I want to convince you today why your microbes may be more important than your genes, and I want to talk to you about this whole phenomenon of epigenetics. We know genetics is the study of our genetic code, the DNA that we inherit, the DNA that basically provides our body the instructions to make all our cells, our tissues, our organs. Epigenetics is a study of how our body creates chemical tags that change that expression that basically turns genes on and off. So if any of you in the audience thought that our genes are our destiny, you get what you get and you don't get upset, I'm here to tell you that your genes are just a suggestion. And this is where I make my very bad joke, and I say it's like the face a Kardashian was born with. It's just a suggestion. No offense, love the Kardashians, but I can never resist making that little pun.

Robynne Chutkan: So I want to start with a couple brief definitions. First of all, what the microbiome is. I was delighted to see the huge show of hands when Rip asked about the microbiome. But for those who still may not be entirely clear, first to all the microorganisms that live in and on our bodies. So over 100 trillion in all, a whopping billion bacteria in just one drop of fluid in your colon alone. Your microbiome is a more unique identifier of who you are than your own DNA. It reflects everything about you. Where you were born, and more importantly, how you were born. And we'll talk about that in a moment. Where you've lived, what you've eaten, whether you've had a pet, medications you've taken, stress, whether your sister sneezed on you, everything is reflected in the microbiome.

Robynne Chutkan: Microbial cells outnumber human cells about 10 to one. We have about 23,000 human genes and 3.3 million microbial genes and counting, leading some of us to wonder whether we're more microbe than human.

Robynne Chutkan: So what do our microbes do besides make smelly gas? Which in itself is a very important function. They digest our food, they synthesize vitamins. One of the things that happens in the hospital when people come in with pneumonia or sepsis is they get broad spectrum antibiotics. And one of the things that happens shortly after they get those antibiotics is that their blood stops clotting. And we're usually alerted by this by the phlebotomist who's drawing blood every day and they'll say, "This patient's blood isn't clotting." So we start giving them vitamin K, and that happens because the antibiotics kill off so much of the microbiome that we don't have enough bacteria to help synthesize vitamin K. So that's an example of one of the vitamins that our bacteria synthesize that we can't make on our own.

Robynne Chutkan: The metabolize drugs. Your response to different drugs, whether you're a fast metabolizer or a slow metabolizer, has a lot more to do with your microbiome than it has to do with genetics. It's why some people need only a tiny little dose of a drug and other people may need a lot or not respond at all.

Robynne Chutkan: Our microbiome helps us neutralize toxins. It trains the immune system. And this is crucially important, and we're going to come back to this in just a moment when we talk about the hygiene hypothesis. Training the immune system. Kids who are not exposed to enough germs early on have a much higher risk for developing autoimmune disease down the road. Because they need, the bacteria need that exposure to be able to tell the immune system okay this is really serious, this is Ebola. Let's make a big fuss. This isn't so serious, this we can completely ignore. It's that sort of training, and that has to happen at a really early age or a bad things happen. We'll talk about that again in a moment.

Robynne Chutkan: Our microbes also turn genes on and off. It's one of these very important epigenetic factors. So if you ever wonder how come everybody in the family has a certain disease and then all of a sudden you don't see the disease developing, or identical twins. Why does one identical twin develop a disease and the other doesn't? It's because they don't have identical microbiomes, because the genes are identical. But their life experiences, their environment, their diet, their stress, all of those epigenetic influencers are different.

Robynne Chutkan: So in medical school, we were taught really well how to diagnose things. In terms of what this is. Well this is Crohn's and ulcerative colitis, and this is celiac disease. But that really essential question of why. Why do people get Crohn's disease, or ulcerative colitis, or celiac disease, or rheumatoid arthritis, or Eczema, [inaudible 00:07:14]? Why? And the answer lies well beyond the genes.

Robynne Chutkan: Our microbiome is one of the most important factors for influencing disease expression. My area of interest is inflammatory bowel disease, Crohn's disease and ulcerative colitis. And I had the incredible good fortune of doing my GI fellowship at Mount Sinai Hospital where Dr. Crohn, Dr. Oppenheimer, Dr. Ginzburg. Only Dr. Crohn ended up with his name on the disease but it was actually three of them describe Crohn's disease in the 1930s.

Robynne Chutkan: And Mount Sinai is a terrific hospital. There are about 70 gastroenterologist on staff, all things inflammatory bowel disease. But nobody ever asked that question, why does this patient have Crohn's disease? We were very good at diagnosing it and treating it. But this essential question. In my own medical practice, I began to see a thread in my Crohn's and ulcerative colitis patients. A thread that I'm going to talk about here in terms of how these people were born, what their early life influences are, the food they'd eaten, the medications they'd taken, and realize that it wasn't just incredible coincidence of disease falling out of the sky into our laps, but there was a little breadcrumb trail.

Robynne Chutkan: And I thought well if you can sort of follow this trail for how disease developed, maybe you can develop disease. Right? And my personal interest in it came after my daughter was born about 13 years ago with a full medical mojo if you will, of lots of antibiotics and C-section, etc. And my main interest is preventing her from developing autoimmune disease later on. So let's take a look in a little more detail.

Robynne Chutkan: Now you may think that the most important day of your life was your first day of school, or your first day of college, or perhaps more importantly, your first day at Plant-Stock. But I'm here to tell you that this, the day you were born, watch carefully. Notice as the baby's head crowns, it turns posteriorly to face the tush. What better way to swallow a mouth full of microbes than for the head to turn posteriorly.

Robynne Chutkan: So this moment here is actually the most important day of your life, because that's when you get all your founding species. Now the fetus is not exactly sterile, but it's pretty close. So how do we go from almost germ-free fetus to 100 trillion microbe super organism? It starts there. And what we know is that babies who are born via C-section, which is now a startling almost one in three births in the U.S., some from medical necessity like breech, etc., but a lot for convenience and for commerce. We know babies born via C-section have higher rates of allergies, asthma, autoimmune diseases, and obesity. And we know that this difference follows them into adulthood. We know that babies born vaginally or colonized with the mother's healthy bifido founding species as they should be. Babies born via C-section are colonized with hospital acquired staff and other not so great microbes if you create a pecking order.

Robynne Chutkan: We also know that in terms of breastfeeding, when I was in medical school, I used to see in the clinic these signs about breastfeeding decreases rates of Crohn's disease. And I thought that's crazy. How can breastfeeding decreased somebody's likelihood of developing Crohn's disease when they're 25? That's those [inaudible 00:10:40] people with their propaganda. Turns out they were right. The third most common ingredient in breast milk is something called an HMO. Not the medical kind, but human milk oligosaccharides. Human milk oligosaccharides are completely indigestible by babies. Why is a third most common ingredient in breast milk something that a baby can't even digest? Because it's not there to feed the baby. It's there to feed the baby's bifido, the baby's founding species, so that those populations can grow and that bacteria can help the baby repel staff on the mother's breast and nipple. Incredible. You could not design a more clever system if you tried.

Robynne Chutkan: So babies who have the misfortune like our daughter being born via C-section, not being breastfed for very long, getting IV antibiotics at birth prophylactically and all the rest. You start to see the breadcrumbs now of how those kids then are set up later on for autoimmune disease.

Robynne Chutkan: In the 1950s in post-industrial London, David Strohn 00:11:47]who was a lecturer with the London School of Tropical Medicine and Hygiene, was tasked with trying to figure out why they were seeing skyrocketing rates of asthma and hay fever, and Eczema in children in London at that time. If you look at this graph here from the 1950s, you see this very steep rise with Crohn's disease, type one diabetes, MS, Asthma. There are about 70 other autoimmune diseases we could superimpose on their. Diseases that I like to think of as modern plagues that are really, we're talking about the last century for most of them.

Robynne Chutkan: So the British government asked David Strohn who was an epidemiologist to try and figure out why they were seeing this epidemic of hay fever and Eczema in British children. And he set out on a 28 year epidemiological study following 17,000 kids from birth to adulthood. And he found two startling facts. The first was that children who were from large families with lots of siblings sneezing on them and giving them chicken pox, and measles, and a cold had very low rates of Hay fever and Eczema, these prototypic autoimmune diseases as adults. So that was the first thing. It was good to be in a large family.

Robynne Chutkan: The second thing he found, which was even more surprising, was that children who were from more affluent households who had loftier standards of personal hygiene. Now, this is in 1950s. These days, affluence does not mean loftier standards of personal hygiene. But back then in post-industrial Landon, it did correlate. So we found that the wealthier kids who were bathing all the time had the highest rates of Eczema and hay fever.

Robynne Chutkan: So this turned everything we thought we knew in the medical community on its head. The idea that it was not just not good to be clean, but it was bad to be clean. And that perhaps all this super sanitizing, and scrubbing, and bathing, and washing was actually creating, let's skip this one, was actually creating this. So if we look at a map of the world today, we still see this north south distribution. So this is showing MS, and we see hot areas in North America and Western Europe, and very low rates. There's a little hot area in Australia, low rates of these diseases in sub Saharan Africa, Southeast Asia, etc.

Robynne Chutkan: So the countries that are more industrialized, that have more widespread sanitation, chlorine in the water, etc., these are the countries that have high rates of autoimmune disease. And as we look at countries as they become more industrialized, we see this a lot in India and in the Middle East, we see skyrocketing rates of Crohn's disease, etc.

Robynne Chutkan: We know that antibiotic use, so people leaving the farm for the factory was one of the significant factors in terms of seeing these autoimmune diseases. But we know that there are other things we'd been doing in terms of super sanitizing ourselves, and antibiotic use is a huge one. Antibiotic use damages a microbiome. There is no selective antibiotic out there that only kills off the bad bacteria. In fact, as bad luck would have it, our essential good microbes if you will, are more fragile and more susceptible to antibiotics than the pathogens. Five days of a broad spectrum antibiotic will take you from that to that, will remove about a third of your gut bacteria. And there's no amount of a probiotic that's ever bringing that back. So the analogy I like to use for probiotics is like taking a full bath tub of water and draining out all the water, that's the antibiotic. And the probiotic is taking a cup of water and pouring it back in and say, "Okay, I'm ready to take my bath."

Robynne Chutkan: So this idea that you know you can just eat yogurt, which we all know is just a less sweet form of ice cream. You can eat yogurt or you can take a probiotic, and all is well. That is magical thinking. The most important thing is judicious use of antibiotics. Antibiotics have been one of the greatest medical discoveries of all time. They could have saved millions of lives with the great plague. They save millions of lives every year, but they're also incredibly overused. The estimate, the conservative estimate is that more than 50% of antibiotics prescribed today are unnecessary. The average American child will receive over 18 courses of antibiotics before their 18th birthday. Almost all of them for things like air infection, strep, etc., that do not require antibiotic treatment.

Robynne Chutkan: So this stuff is not free. This stuff does irreparable damage to the gut microbiome. And if you're a kid, like our kid was a C-section baby who was mostly formula fed, any additional course of antibiotics they get is bringing them one step closer to a modern plague. And that's very important to be aware of.

Robynne Chutkan: So our conventional way of thinking about disease is Pasteur's germ theory. And germ theory says that a bad actor gets in and makes us sick. And that's still very true of certain things like Ebola. Again, I'm not taking my chances with Ebola.

Robynne Chutkan: So there's certain pathogens that are so very virulent, that they will make almost anyone who they come into contact with sick. But most of us don't get sick because of a bad bug. Most of us get sick because our terrain is unhealthy. We don't have a good gut garden.

Robynne Chutkan: So if you think for example of a cruise ship outbreak of norovirus, there are 4,000 people on the cruise ship, but only 2,500 gets sick. Why don't the other 1500 get sick? Is it because they weren't exposed to the virus? Chances are they were all exposed to the same thing. The people who get sick are likely the ones who were C-section babies, antibiotics at birth, formula fed, taken lots of antibiotics, lots of steroids, lots of what my GI colleagues prescribed Proton-pump inhibitors, which we know dramatically increase the rate of enteric GI infection, C. diff, etc. So it really is about terrain. And those of you who have transitioned to a plant based diet or who are in transition, that's probably one of the first things you noticed is you don't get sick all the time anymore. That's not an accident, and that's not because you're not coming into contact with influenza or strep, etc. It's because your terrain is different.

Robynne Chutkan: I want to talk about two diseases in particular, inflammatory bowel disease as just the prototype of one of these autoimmune diseases. And then we're going to spend a minute talking about obesity.

Robynne Chutkan: So inflammatory bowel disease as one of the diseases I study is really a disregulation of the mucosal immune system. And what that means is your body is overreacting to its own bacteria. In the case of rheumatoid arthritis, your body is overreacting to its joints and it's destroying joint tissue. In the case of Eczema or psoriasis, it's happening in the skin. With inflammatory bowel disease, it's happening in the gut. So it's an inappropriate response to microbes that are for the most part benign, but your immune system, it's again, this exaggerated immune response.

Robynne Chutkan: We know that there's a genetic basis for inflammatory bowel disease. We know there's familial clustering, there's family history, there's an increased risk in relatives. But this is not a genetic disease. There's an environmental trigger that happens that creates inflammatory bowel disease. So this is a meta analysis. There's a microbial signature in Crohn's disease where we see this increase in mucosally associated bacteria. A decrease in microbial diversity. Diversity in the microbiome is as essential as diversity in the external world. Without it, we die. We need all the different organisms. So we see in inflammatory bowel disease, just like we see in MS, and diabetes, and obesity, and lupus, we see a decrease in microbial diversity and we see a decreased production of butyrate, which is a short chain fatty acid. And which is sort of a marker for a healthy microbiome and the details are not so important.

Robynne Chutkan: So this is a meta analysis I wanted to talk about. This is a study that was actually done by some of my colleagues at Mount Sinai Hospital, a meta analysis where they pooled several studies and they looked at over 7,000 patients with inflammatory bowel disease. And they found that the risk of Crohn's disease was markedly increased in people and especially children who had taken previous antibiotics.

Robynne Chutkan: That was the biggest epigenetic factor in terms of developing inflammatory bowel disease. Even more shocking, the highest risk was for two antibiotics in particular, metronidazole, and ciprofloxacin, the two antibiotics that for decades we have used to treat flareups of Crohn's disease. The very drugs we're using to treat the disease are implicated in causing the disease.

Robynne Chutkan: We know that babies who are given antibiotics in the first year of life have a threefold increase in developing inflammatory bowel disease, and that increases by about 7% per year with each course of antibiotics.

Robynne Chutkan: The other thing we know, so that's the bad. Antibiotics bad, increase the risk of inflammatory bowel disease and many other autoimmune diseases. What's good? What can we do to protect our kids besides trying to birth them vaginally and nurse them, etc. We can help them live dirty. This was a study that was published last year, and it showed that rural residents during early life was associated with a lower risk of inflammatory bowel disease. It's protective, especially in young children who have had early exposure to antibiotics. So we can get our kids out there and get them dirty.

Robynne Chutkan: I want to talk about twins for a quick second. This is what we think of when we think of identical twins, right? They pretty much look the same. But sometimes identical twins look like this. And if you're identical twins that look like this, you're on the Oprah Show as these two are.

Robynne Chutkan: These identical twins, one lean, one obese, researchers at Wash U transplanted their microbes. They transplanted the microbes from the obese twin and the lean twin into germ-free normal size mice. And within a very short period of time, the mouse who received the microbes from the obese twin gained weight. The mouse who received the microbes from the slim twin did not gain weight, without any change in diet or exercise. Now we've known that we can transplant microbes from an obese mouse to a germ free slim mouse, and that that most will gain weight. But we'd never done it from a human to a mouse before. And what this told us is that the microbiome is hugely responsible for what we call the energy harvest, which means how many calories are extracted from the food and either stored as fat and used as energy, etc. How do they do these?

Robynne Chutkan: Microbes can either speed up or slow down the amount of time it takes for food to go through your GI tract, allowing for more or less calories to be absorbed. Our microbes can affect the secretion of insulin and other hormones that essentially influence fat deposition, fat storage. And our microbes can consume extra calories themselves. So this idea of calorie in, calorie out. Or this idea that people who struggle with their weight are secretly binging Häagen-Dazs at night is completely, completely outdated and inaccurate. And we know that for the same amount of food, different people will gain and lose different amounts of weight. And these studies show that really well.

Robynne Chutkan: So obese mice have a very clear microbial signature. They have like the Crohn's patients, low diversity and low levels of certain bacteria. And we see almost an identical microbial signature in obese children.

Robynne Chutkan: We can predict obesity with about 58% accuracy looking at DNA, and with 90% accuracy looking at the microbiome, looking at the constellation of bacteria present or absent.

Robynne Chutkan: So I want to tell you now about three important studies to do with food that I want you to remember. The first is a study by Paolo Lionetti, where he looked at a group of babies in Florence, Italy, and he compared them with a group of babies in Boulpon, Burkina Faso. And what he found was that at birth for babies who are born vaginally and breastfed in early infancy, the microbiome was virtually identical between the Italian babies and the babies from Burkina Faso. But as soon as the children graduated to a table diet, everything changed. The kids in Florence, Italy had microbes that are associated with diarrheal disease, with obesity, with autoimmune disease. They had very low levels of those essential short chain fatty acids that are associated with a healthy microbiome.

Robynne Chutkan: The kids in Florence were eating a standard American diet. It was pizza, and pasta, and gelato, and osso bucco. So it was basically high fat, high sugar diet, very low in plant fiber. The kids in Burkina Faso were eating locally grown yams and greens, and I believe in his article he said enlivened by the occasional termite or free range chicken, very rarely. Was a plant-based, high fiber diet. Those children had the microbes that were associated with leanness, and anti-inflammatory microbes. They had double the levels of short chain fatty acids.

Robynne Chutkan: Now, what's really important here is that neither group of kids were sick. We're talking about two year olds. Both healthy. But the Florentine children eating the western diet, we were already seeing the beginnings of disease in their microbiome. So when other speakers have talked today, Michael Greger talked about how coronary artery disease starts in childhood. Same thing. It gets laid down really, really early.

Robynne Chutkan: So you might say well this is very interesting, but Burkina Faso and France, Italy, are very different environmentally. So maybe what we were seeing were the environmental differences that were now coming to light. So this was a study from Harvard from a couple years ago where they took nine volunteers and they put them on essentially an Atkins type pork rinds, prosciutto, cheese diet for five days. And then they took the same nine volunteers, they rested them for two weeks, and they put them on a high fiber, low fat, plant based diet. Jasmine rice, lentils, fruit, etc. No animal products. Within 30 hours of the food hitting the gut, everything changed. Not just the bacteria. Dramatic decreases in the Bilophila, the bile loving bacteria that are important for breaking down meat products, but are also associated with inflammation and diarrheal disease. So those drop to very low levels. But even more astounding, genes started turning on and off within 30 hours of the diet changing. So I'll take Rip's week and I'll distill it down to 30 hours in terms of what it takes to start changing the microbiome. So this is a second study.

Robynne Chutkan: The third study was a very cool study, a collaborative study between Imperial College London and University of Pittsburgh. They took 20 African Americans and 20 Africans from rural South Africa, 20 black Africans from rural South Africa. And they swapped the diet onto very closely controlled circumstances for two weeks. The American group on the African Diet as you can imagine, did well. They had less inflammation in the colon, and they had reduced biomarkers of cancer risk.

Robynne Chutkan: Now two weeks is too short to see whether there were real differences in colon cancer. But the biomarkers like ... antigen and a lot of other these biomarkers we know about decreased dramatically.

Robynne Chutkan: The poor South Africans, they did not fare so well on the American Diet. They had a dramatic increase in cancer risk after just two weeks. So if you've ever wondered whether something like colon cancer, whether there's a dietary basis to this, wonder no more.

Robynne Chutkan: So what were these rural South Africans eating that was so protective in terms of their colon cancer risk? They were eating MACs, microbiota accessible carbohydrates. A lot of the same things. We've been eating here today. Quinoa, and brown rice, and beans, and beans, and beans, and more beans. And this was what was protecting them. These high fiber, low fat, high degree of indigestible fiber.

Robynne Chutkan: What sort of bacteria does that die at produce? Things like faecalibacterium prausnitzii. F prausnitzii as it's affectionately known, is one of the most prevalent bacteria in the gut of vegans. It has a protective role in metabolic diseases like cardiovascular disease, stroke, etc. There is a strong correlation with again, these healthy short chain fatty acids. And it is associated with a significantly reduced risk for cardiovascular disease, colon cancer, diabetes, and obesity.

Robynne Chutkan: But you can't just go and borrow some of your vegan friends' F prausnitzii if you happen to be a devoted carnivore and worried about colon cancer, etc., because the F prausnitzii I need to be fed.

Robynne Chutkan: So this is a whole issue with probiotics. You go borrow some healthy probiotics from the pharmacy, and you ingest them. And within about 20 minutes, they're dead. And the ones that do survive, you end up pooing out later on or the next day. So it's all about growing your own good gut garden. All of us have enough of our founding species to really create something magical in our microbiome. But you have to feed the bugs. You can't hack it with a probiotics.

Robynne Chutkan: In the last century, we've seen this dramatic decrease in communicable diseases like measles, hepatitis, tuberculosis. And the reality is that the widespread sanitation that I've been knocking is in large part responsible for this decrease in communicable couple of diseases, right? So I'm very glad that I don't have to worry about getting cholera from the drinking water, etc. But at the same time, the pendulum has swung the other way. So now I don't have to worry about cholera from the water, but I have to worry about non-communicable diseases like Crohn's and ulcerative colitis, RA, Eczema, cirrhosis, etc. asthma, diabetes.

Robynne Chutkan: So we've seen the shift from the communicable diseases that were killing people to the non-communicable modern plagues. And many of these changes are tied to changes in the microbiome.

Robynne Chutkan: If we look at this triad of our innate immune system and the health of that, and when we talk about that, we're really talking about the health of our microbiome. We look at environmental factors like diet. You put it all together, you mix it all up in a bag. The microbiome, the immune system, the diet. There is not one organ system that is not affected. Inflammatory bowel disease, fatty liver, heart disease, obesity, cancer, particularly colon cancer. Pulmonary disease and a-top. I have a whole talk on allergy and asthma, and the contribution of the microbiome. Rheumatoid arthritis, ankylosing spondylitis, diabetes, and what I don't have a pair is the brain. Parkinson's, Alzheimer's, depression, anxiety, schizophrenia. We're finding a huge microbial contribution to these diseases.

Robynne Chutkan: So this is a quote from my first book, Gutbliss. If you want to encourage a growth of good bacteria, heal inflammation, improve motility, crowd up parasites, eliminate yeast, get rid of belly fat, dissolve gallstones, balance your pH, quiet down your irritable bowel syndrome, prevent diverticulosis, cut your risk of colon cancer in half, boost your energy, lose weight, banish your bloat, and really glow. Then the single most important thing you need to do is eat greens every single day.

Robynne Chutkan: The most commonly prescribed medication in my gastroenterology practice is actually the green smoothie. And I know that Dr. Esselstyn told us to chew our greens earlier, but I'll tell you for a lot of my patients who have a compromised GI tract, it's difficult for them to be able to get in that much solid food. So having them blend them in addition to the salad and stuff they get in has been tremendously helpful.

Robynne Chutkan: Our practice is almost exclusively nutritional and lifestyle therapy. People come to us to get off their Remicade and Humira and prednisone, etc. And 20 years ago when I was finishing my GI fellowship 21 years ago, if you had told me that you could heal Crohn's and ulcerative colitis with diet, I would have said you were crazy. And now it's my distinct pleasure to do it every day in the practice. Thanks so much.

Rip Esselstyn: I want to thank my co creator of the podcast. Scott Battishill of 10% media. Laurie Kortowhich, producer extraordinaire, and director of Engine 2 events. Ami Mackey, Engine 2's curator of creative content. Wade Clark with Bumble Media, our audio engineer. And Carrie Barrett for technical production.

Rip Esselstyn: I have to thank my parents Anne and Esse, who have been such guiding lights and inspirations over the years. As well as the great pioneers of this movement who have been pushing this boulder up the mountain. As they say, we are standing on the shoulders of giants.

Rip Esselstyn: Remember, if you're digging the show, please rate us at Apple Podcasts, Spotify, Stitcher, Google Play, or wherever you get your podcasts. And with that, let me say peace, Engine 2. Keep it plant strong.

Ami Mackey