August 30, 2023 • 44 mins
Did you know that cycling has been proven to reduce the risk of heart disease and cancer and lift your mood?
This week, Sarah and Erika talk to Kristine Krueger, a passionate cycling enthusiast and full-time physician devoted to the field of gastroenterology. In this compelling episode, Dr. Krueger discusses how she found her passion for cycling and health after facing down and beating breast cancer. Listen as she discusses how cycling helped lift her depression and navigate her through a difficult time.
We also listen as Dr. Krueger provides insights into gut health. She explains the gut impact on our bodies and the importance of positive gut health lifestyle choices, including the best way to leverage vitamins and supplements for overall health.
Dr. Kristine Krueger is a Professor of Medicine and chief of Academic and Clinical Affairs in the Division of Gastroenterology, Hepatology, and Nutrition at the University of Louisville School of Medicine. Her interests in the realm of gastroenterology include helping patients focus on healthy eating and lifestyle, gut microbiome, and alternative medicine for gastrointestinal illnesses. Dr. Krueger was born in Texas, the daughter of an Air Force Pilot, and spent a large part of her childhood and youth moving from town to town. She graduated from Florida State University, where she was a proud member of the FSU Flying High Circus, and then completed her medical degree at the University of Florida. Her proudest accomplishments include raising her daughter (a veterinarian) and her son (an engineer and chef). Besides her busy academic life of seeing patients daily, performing endoscopies, and teaching, she is an avid cycling enthusiast.
What is a 'Cycle’?
Our bodies have natural body cycles, and more diseases become prevalent as we age. Taking care of our gut microbiome and enjoying regular exercise is crucial to maintaining a good health standard.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
S1 (00:02):
Welcome back to Connections in Flight. I'm Erica. I'm Sara.
Join us as we have another meaningful conversation about navigating
our current life flight. There are. Yes, there's a big
water bottle. Yeah. I'm drinking that on purpose because of
our guest today. I had the crappiest lunch. Like, I'm
just going to say Pop tarts are involved. So I
(00:23):
was like, Get ready for the podcast. And I was thinking,
Oh my God, I'm gonna like, at least hydrate and
flush out. Hopefully my lunch. We can't be perfect all
the time. No, no. So today we have a really
stellar guest. Her name is Dr. Christine Krieger. She is
a professor of medicine, chief of Academic and Clinical Affairs
(00:45):
in the Division of Gastroenterology and Hepatology and Nutrition at
the University of Louisville. She's pretty much a rock star
over there. She went to the University of Florida School
of Medicine. She gave me some of her college activities.
And it says she was in the circus. I saw that.
I've got to find out what that was. Well, I
knew and currently, besides working full time, having a lot
(01:08):
of interest and of course, gut microbiome.
UU (01:11):
Alternative pathways of healing. Got all of that.
S1 (01:16):
Her most proud moments are the fact that she's a
mother to a daughter who's a veterinarian and a son
who's an engineer and a chef. She does sprint triathlons,
but she's very athletic, obviously, which leads to her word,
which is cycle makes so much sense. I can't wait
to hear how she talks about it. But no, you know,
when I think of our life cycles in seven years
(01:38):
and gut biome and microbiome and yeah, I mean, I'm
jumping the gun here, but I have heard her speak
before with you and I just I feel like every
time she says something, I learned something new and I
think about it for a long time. Yeah. I've actually
had her speak twice at those health salons, and people
just can't get enough of what she says. And honestly,
(01:58):
this would be my third time speaking with her in
a similar format. And like you said, I just always
learned something new, so. Well, let's go. All right. Thank
you to Betterhelp for sponsoring this episode. Betterhelp is the
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(02:19):
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(02:39):
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(03:02):
Com slash connections and flight. That's better. Capital b e.
T e. R h e lp slash connections and flight.
Welcome to the podcast. Thank you very much. Erica and
I are so happy to have you here. We'll just
start as we start with most of our guests and
just tell us like where you grew up, where you're born.
S2 (03:23):
Well, I was born in Texas. My father was an
Air Force pilot. And I think I moved 11 times
before going to college. I got used to being the
new kid in the class and had to learn how
to open my mouth. So I very much enjoyed moving
all over the country. When my father went to Vietnam,
(03:45):
my mother, unbeknownst to me, had been a nurse. She
had been taking care of me and my sister, and
I didn't even really realize that she'd had a career
that she put on hold. So when Daddy went to Vietnam,
mom went back to work and we didn't know if
we would ever see him again. But she would come
home and say these wonderful things about what she did
(04:07):
in the operating room and what they did for patients.
And that's actually when I knew I was going to
go into medicine. I was 12 years old.
S1 (04:17):
Wow. So you were 12 when your dad went to Vietnam? Yeah.
Do you mind if we ask how old you are
right now?
S2 (04:23):
I'm 63. I'll be 64 in December. All right.
S1 (04:27):
You're wearing 63. Very well. Thank you. Let me ask you,
did you see your dad again? Yes. Oh, thank God.
S2 (04:34):
I know. I mean, it was a time there were
no cell phones. So we would wait for these little
eight track tapes. And I remember having some monetary dreams
where I knew something bad was happening. His barracks got bombed,
his best friend didn't make it. And I had a
dream about it. Told my mom even before the tape came.
So there's that kind of. Yeah, you know, weird energy. Yeah.
(04:59):
Across the Oh.
S1 (05:00):
We talk about energy a lot, so we totally believe that. Yeah.
S2 (05:04):
But no, daddy came home and we continued to move.
And then in I think it was in Omaha, Nebraska,
where I graduated from high school, my sister got recruited
on a swimming scholarship to Florida State. And I followed
her because at that time I wanted to be with
my sister. And that began living in Florida and going
(05:24):
to medical school. And that's how it all began.
S1 (05:28):
What year did you graduate medical school?
S2 (05:30):
In 1985.
S1 (05:31):
Wait, wait, wait. I have a question. Before medical school.
The circus. Oh, we promised. We want to talk about
the circus waiting. Oh, that's in your bio. Thank you. Like,
Wait a second. We have got to know what that
was about.
S2 (05:44):
So Florida State University has a circus that is a
I think it's a varsity sport now. And it doesn't
have animals and clowns and things like that. But it
had intense acrobatics. The trapeze I was too tall to
be a a flyer, as we call the girls, but
I still get to participate in all kinds of different activities. Juggling,
(06:08):
walking a wire.
S1 (06:10):
Hi.
S2 (06:10):
My gosh. And my act was over a net and
I never broke anything. We didn't do it without nets,
but I never even fell during an act so that
it was extremely fun. We did all the rigging. When
we would go around, we traveled a little bit. We'd
have to put the nets up and take them down.
We made our own costumes. It was a really neat
(06:33):
time and amazing.
S1 (06:35):
I have never met anyone who says I was in
the circus. Yeah, that is fantastic. What a awesome college
kind of pastime. I think it sounds amazing. I'd love
to be on the trapeze. So you were in the
circus and you got into medical school. You graduated medical
school in 1985. Tell me about mid-eighties being a woman
where you like, I'm going to be a GI doctor then,
(06:55):
or did you wait or did you go straight to fellowship?
S2 (06:57):
Well, after medical school, then you do what's called a residency.
And I remember the first years, your internship year, and
then you get your medical license as soon. I mean,
it was July 2nd of the next year. I had
my license and I moonlit a lot in order to
pay my loans. And Moonlighting showed me the emergency room world,
(07:21):
which I thoroughly loved. So as I was then, now
a resident, I continued to do emergency medicine all throughout
my residency, even into my GI Fellowship. There were no
workout restrictions back then, and so you could work as
much when you weren't in your training, which was great
because I was able to pay all my loans off.
S1 (07:41):
Were you doing an internal medicine residency and moonlighting in
the E.R..
S2 (07:45):
And moonlighting in various emergency rooms around the area and
loved it. And I was in my fellowship for GI
at the time, but I didn't want to give up E.R.
but I decided that I liked them both and that
I didn't want to have to do another E.R. residency. So.
S1 (08:01):
So you hit the GI tract straight out.
S2 (08:03):
My first academic job was Mobile, Alabama, very small clinical
focus group. And from there I moved to UK in
97 to 2000 when you of L built the digestive
health center and I was asked to be the director there.
About nine of us came over from UK.
S1 (08:21):
Tell us about kind of your more adult life than
you were working you were married.
S2 (08:26):
So I'm I am now remarried. The father of my
two children. He also moved up to UK. And shortly thereafter, though,
our relationship fell apart. Sometimes a therapist will tell you
it'll take five years to figure out what happened. And
I think that's true. And you finally come to the
grips of what was wrong with you, what you could
(08:50):
have done to keep that relationship going. And you finally
then learn a lot about yourself. So hopefully then you
don't make those mistakes again. I decided with a full
time job that I would raise my kids pretty much myself.
They were five and seven, I think, when we broke
up and I became probably the dark part of my
(09:11):
life that next ten years because. I thought I was invincible.
I thought I could do it all and fill in
all the gaps. And I think my stress really, really, really,
really accelerated. And that eventually led to a health problem.
S1 (09:30):
I'm curious, did you reflect on your mom having to
step back into work when your dad was gone? Was
that a helpful kind of role modeling for you during
that hard time?
S2 (09:40):
Yeah, well, my mom was the strongest lady I know.
She's a little pistol, but she's strong and she's somebody
I talked to every day. So I constantly had help
and encouragement. She's a very positive individual. I got strength
from her. But I it was at at the expense
(10:00):
of my own health. And I know I don't think
my kids suffered. I was fortunate enough to be able
to hire some people to pick them up after school,
to take them to their sporting events. That was challenging,
to find people that only want to work part time,
you know, every day from 2 to 6 or something.
But it worked. I'm happy that from a health standpoint
(10:23):
that I always managed to have sit down and dinners
with my kids. We did very little fast food. Dinnertime
was special, as it was with my mom that we'd
sit at the table and we didn't say bad things
about school or anything. It would be what was the
best part of your day. And I really think that
holds families together to have a time where you're sharing
(10:46):
like good food and you're also talking about positive events
of your day right now.
S1 (10:52):
Well, here you are working with the children. And what happened?
S2 (10:56):
I felt a breast lump when we were on a cruise.
And I remember that my kids were now teenagers and
they didn't want mommy to be taking pictures of them anymore.
And I was still very, very much wrapped up in
their lives. I felt that lump and it was like
August and. I ignored it. And I don't know why.
(11:19):
I really don't. In December, I decided to do something
about it because it felt different from a cyst. It
didn't hurt. It. It just felt like it wasn't part
of me. And so I got it evaluated and I figured, well,
maybe it's just fibrosis stick stuff. I've had that before.
And when the biopsy came back positive, I remember the
(11:41):
phone call from the very nice guy that did the
biopsy and he said, I can't believe I'm telling you this,
but it's cancer. So. I told my children the time.
My son was 15. And I just met a really
wonderful man. I did not date, literally. Like, maybe that's
(12:04):
why I went and had the biopsy done. Literally, it
was like a month before that I met a very
nice man. My son's response as a typical 15 year
old was, Is your boyfriend going to dump you? And
I and I said, Well, if he does, he's not
the right one. But what's etched in my mind forever
(12:25):
and Make me cry was when I told my daughter
and my daughter, Lips started trembling and she said, But Mommy,
you do everything right. After I went through surgery and
all of that, I read a lot about breast cancer.
And we don't talk about when girls were sports bras.
(12:46):
They crush their breasts. That's injurious. The other one was
it was emerging to be very curious about the vitamin
D connection. And I went ahead and I checked my
vitamin D level and it was below the recommended amount
of 30. I believe the range is really high, 30
(13:08):
to 100. I've since learned and taught you really want
to level around 50 or 60, and it might be
hard for people to get there with sunscreens and the
ozone layer and whatnot. But I truly believe and so
do endocrinologists believe for bone mineral density and sports physiologists
for muscle recoil cycling that and psychology. Mood and mood, mood. Huge. Erica,
(13:35):
there have been a few of my colleagues that bring
their kids to me. I'm not a pediatric GI doctor
but that have some GI illnesses and they maybe are
18 or 19. And I look at these kids and
they're inside all the time on their games and they're pale.
And I say, you probably have a low vitamin D level.
And they did. I mean, I've had like a handful.
(13:57):
And with giving them a supplement, they don't have to
take their mood medication anymore. So yeah, I think vitamin
D is a big story. And women who want to
reduce their risk maybe have their primary care doctor check
them and that might be a strategy in the future.
S1 (14:16):
I have like a lot of things I want to
get to the vitamin in the health changes that you
may have made after your diagnosis of cancer. But I
do want to stay on this one topic of, I guess, denial.
And I'm just curious to kind of go down this
rabbit hole right now because I am a breast radiologist,
so I do breast biopsies and you do talk to
so many people who are like, I knew it was there,
(14:37):
you knew it was there, but like you didn't act
on it. And I'm just wondering if we can talk
a little bit about that right now. Like, what do
you think about that, Erica? I think denial is exactly
you're denying the fear of what if I am vulnerable, Right.
You said here here you had all of this, these
things you've overcome. It's almost like it can be subconsciously
(14:59):
avoiding the fear. It's so interesting what I mean, if
someone's listening and thinking, Oh, I have a whether it
be a lump in the breast or something else, that
just I love what you said. It just didn't feel
part of my body. No, it didn't. And that I
think that is so key. Like just body self awareness
because so many lumps and bumps that we have, they
are normal, like you said. But when something doesn't feel right,
it doesn't feel like me. That's definitely a signal. What
(15:21):
do you think are some questions or maybe some self
talk a woman could do right now if she thinks
she has a problem somewhere and is kind of stuck
in that denial?
S2 (15:29):
Well, as you too are talking about that, I reflected
on that. And for me personally, I was depressed. So
it's interesting. You talked about mood and vitamin D, and
I had never been diagnosed with any depression. I really
didn't even consider myself depressed, but I was depressed. When
(15:51):
I look back at the couple of years prior to
my diagnosis, I stopped really taking care of myself. I
didn't really exercise. I never really carried a lot of weight,
but I wasn't in very good cardiovascular shape. I think
the depression is what people don't label necessarily, and then
they get in that vicious spiral. And I do think
(16:14):
there's a significant link to a lot of cancer and depression.
So I guess what I would say to people is
the flip side is you can be cured. There are
fantastic cures. So, you know, I'm not going to say
it's easy to get over your fear or to snap
out of it or change your mood or, you know,
(16:35):
because those things take time and reflection on all of that.
The night I had my bilateral mastectomy and the reason
I had bilateral is because there were issues on the
other breast two, and they told me that they would
have to like look forever. And yeah.
S1 (16:50):
You don't have to defend having a bilateral. I support.
S2 (16:52):
That. Yeah. So but I remember the nurse that night
just how fantastic she was and how caring she was
because I had these drains and stuff and she was
just really careful not to cause me any pain when
she put the pillows and everything. I mean, people were
so wonderful after the fact. They were not pejorative. I
didn't feel stigmatized at all. They were fantastic.
S1 (17:16):
Did your depression worsen while you're undergoing treatment for cancer?
S2 (17:20):
Here's the funny thing. I remember telling a dental hygienist,
You know, I turned 50. Fell in love and got
breast cancer. I changed my mood. I started taking care
of myself. I had felt the support and love around
my new boyfriend. When he found out I was going
to drive myself to the hospital for my bilateral mastectomy.
S1 (17:43):
And of course you were.
S2 (17:44):
And. And I was. And he said, I will break
both of your knees. You do that. And it was
me just realizing that you have you're the one that's
going to find this. You're the one that's going to
take care of it. And most women find their own
breast lumps. It's great to have screening, but most women
find their. Yeah, if it's palpable.
S1 (18:06):
What are some changes that you made to turn your
health around?
S2 (18:10):
I started cycling. Oh, hear that word.
S1 (18:15):
How did that come into your life?
S2 (18:17):
With my new beau. After the surgery, you know, we
were in a bike store and on a lark, he
was very interested in bikes, and we decided we'd buy
these bikes. Now, I had had an orthopedic injury to
my neck when I was in the.
S1 (18:32):
Circus and all that.
S2 (18:33):
So, you know, the only thing I ever had wrong
was that I'd had some c spine disc herniations, you know,
for being too crazy. When I was young, I didn't
know whether I would be able to do the bike,
but we went ahead and we bought the bikes and
we have never looked back. I can tell you I'm
sitting in this room looking at your airplane and all
(18:55):
of that. There's something about cycling that's hard to explain
why it means so much, but it's freedom, it's exploration.
It's what's around the next corner. It's meeting new people,
seeing the world in a different way and in a
subtle way.
S1 (19:11):
What else do you think helped with the Depression? Did
you get any other. Really avid learning about vitamins because
the vitamin industry I mean, forget it. It's not regulated.
Nobody really knows. You don't know what time of day
your levels are drawn. You don't even know what the
range is from 0 to 1 million. Like, yeah. Can
you give us some?
S2 (19:29):
Sarah I probably read 200 articles to give one lecture
that a colleague asked me to give. I was very
nervous because it was to a group of dietitians. Oh, wow.
And those ladies know their stuff. Yeah, they do. Right?
They're the real experts. So in order to prepare for
that lecture, I read a lot, a lot of scientific
literature refuting, Do you really need vitamins, get older? Or
(19:52):
what stood out consistently in the United States is two vitamins.
One vitamin D is probably across the world as well,
that a third of us will become vitamin D deficient.
And then the next one, I don't know if you'll
guess it, but when I was cycling, I was starting
having cramps. And it's not the potassium.
S1 (20:14):
Magnesium, it's.
S2 (20:15):
Magnesium. That's right. And so then I because I had
to do this lecture for my colleague friend, I had
already started taking magnesium and my cramps got a lot better. Seriously,
it was amazing. But here's the hard part about magnesium
because we've got such strong buffer systems, the majority of
(20:36):
your magnesium is in your bones. And so that's back
to bone mineral density. It's calcium, vitamin D and magnesium
that make the the bone very, very strong. So when
you become deficient, you don't know it because you're just
eating it out of your bones. And so your serum
levels look normal. So it's very difficult to diagnose.
S1 (20:59):
Very. And you're talking about osteopenia, osteoporosis.
S2 (21:02):
Osteopenia, osteoporosis and and rampant. Right, right, right. So you
almost have to just supplement.
S1 (21:10):
You're saying supplement preventatively preventative. Yeah.
S2 (21:13):
Because. Interesting. Yep. And the only people that shouldn't and
you obviously should talk to your doctor about it, but
people with kidney issues, they may have to reduce their
magnesium intake, but for the majority of people, magnesium can
be a safe supplement. There's a range, you know, 200
to 400mg. Not all the magnesium are the same.
S1 (21:35):
Let me ask you, for women like Eric and I
were both. How old are we, Erica? We're for 47.
For 47, would you say take magnesium, calcium, vitamin D?
S2 (21:45):
Yeah, I definitely believe in and doing all that reading.
Those were the two that stood out. And there's reasons,
some of the reasons for magnesium deficiency, which is even
a little more common than vitamin D deficiency, is the
water softeners, hydroponic growth, vegetables instead of in the soil,
and then over use of the soil in the farming
(22:06):
industry where the magnesium comes from. So it comes from
vegetables that grow in the ground and we get it
that way. But if the soil is poor, then the
magnesium quantities have gone down. So yes, I recommend when
people say, what should I do? I will ask about
their diet and make sure they're eating fruits and vegetables,
(22:28):
which makes it easier today when we know that plant
based diets are probably the best diets for us. It
doesn't mean you can't ever eat meat. That's not the
same thing. But eating fruits and vegetables that grow out
of the ground provide most of all of the nutrients
that you need with the exception that you might not
get enough magnesium and you might not get enough vitamin D,
(22:50):
Do I think people need to calcium supplement?
S1 (22:53):
I don't. I've heard that from my doctor as well.
How come?
S2 (22:57):
I guess part of it is a lot of people
have side effects from it and then I think they
eat enough dairy and enough green leafy vegetables for the
most part that they're not as deficient. Again, endocrinologists who
I very much respect at our university, if someone has osteopenia, osteoporosis, obviously,
(23:20):
then they're going to put them on it. I guess
the question is, if you don't have those conditions, should
you supplement, will that help prevent it? And I'm not
the expert there. I we'll find out.
S1 (23:32):
I do want to know, though, when you're talking about
kind of prevention versus how you know, when your gut
isn't healthy, great. Like I know the word microbiome is
floating around with everybody. And how do you know if
your microbiome is healthy? How do you know what to change?
S2 (23:48):
Yeah, loaded question Emerging science. And I think the more
I learn about it, the more I know there's more
that needs to be learned. I do know that your
gut actually tells you what to crave, and that might
be a bad thing if it tells you to crave.
S1 (24:05):
Pop Tarts and Doritos.
S2 (24:06):
Pop Tarts activities or other highly sugary foods. I mean,
there are mice that will be driven to drink alcohol
if they have a certain gut microbiome. So we're unraveling
those mysteries right now. I think I can look at
somebody and to the point where I can look at
someone and say they probably have a healthy microbiome because
their body habitus is more normal, their muscular tone is
(24:31):
more normal, they have less illnesses. I think we're going
to find a lot of illnesses that are related to
the microbiome being out of whack.
S1 (24:40):
Are you born with your microbiome?
S2 (24:42):
Well, your first introduced to bacteria when you're born and
your gut will become colonized. I mean, moms know their
newborn babies don't have normal poop yet and they don't
start having normal amounts of bacteria until they're exposed to
the world, your genetics you inherit, and then you get
(25:04):
the bacterial colonization of your skin and your gut and
everything in your house.
S1 (25:10):
So your microbiome is the lining of your gut. Is
that what we're talking about?
S2 (25:14):
It's not just the lining of the gut, it's the
bacteria and the multiple types of bacteria that are in there.
I mean, there's other things, there's mucin and stuff like that.
But the microbiome is really the microbes. We're we're using
sophisticated technology to class them into big classes. But there's
(25:34):
also a very unknown world of the amounts of viruses
and funguses that are in there as well. So again,
this is a huge field that we don't know a
whole lot about, but we're a lot of people are
highly interested in it. I like to teach that there's
ten times more bacteria inside your gut than there are
(25:58):
cells in your entire body. Oh, wow, what? Ten times more.
And so you better be in harmony with your gut bugs.
S1 (26:08):
And so with a probiotic, which is what so many
people are recommended, how do you know which type to take?
S2 (26:14):
You don't it's not regulated. They're not all created equal.
There's probiotics and prebiotics prebiotics help gut microbes, feed them
like a yogurt. You can take yogurts, which they they'll
advertise they're rich in probiotics. They're right. But here's a
couple of little tips. Don't drain the liquid off of
(26:36):
your yogurt. That's where all of the bacteria are. They
are good for most people. But if a patient tells
me they don't like one particular kind, it upsets their stomach.
Then I say, Well, then try something else, because I
am not going to pretend to be able to guess
in those billions of bacteria and where that person has
traveled and all of that, what particular one is right
(26:58):
for them. Now what I will say is being a
generalist here in this topic, the more variety you have,
the better. So if you were wanting to get a
higher quality yogurt, for example, you would look for the
one that has more species and there's two like major
kinds of probiotics, the lactobacilli acidophilus type help, the upper gut,
(27:23):
and then anything that starts with bifidobacteria helps the colon.
So you want something that's really rich in all of it.
If you ever find a yogurt that has Bifidobacteria Infantis
that's a really good one.
S1 (27:36):
Infantis. Yeah, heck yeah. I'll be looking for that one. Yeah.
Do you tell patients to take probiotics? Well.
S2 (27:43):
Remember, my patients are coming having probably gone through their
primary care doctor and then they've got something wrong with
their gut and it's a bit of a workup to
make sure they don't have an organic illness. They don't
have a food allergy, they don't have hidden celiac. We
talk about what our stools are supposed to look like
and how often and that sort of thing. And it's true,
(28:05):
men are lucky. They have usually one formed bowel movement
a day. Women are lucky if they have one every
other day. Is the average. The medical definition of constipation
is when you don't have a bowel movement in 72 hours.
So I'll get a lot of patients that are swinging
one way or the other or back and forth. And
(28:26):
then if I find out they've been on antibiotics, right.
That interfered, then those are the ones that I say
you might try probiotics.
S1 (28:35):
Point It's so complicated. And I think that there's been
a lot more mainstream talk about functional medicine. Where are you?
Do you feel torn about conflicting opinions about that? Do
they work together Well, What's where are we in the
world of all of the information out there?
S2 (28:53):
I have always, always been interested in other ideas, recognizing
that our Western medical school philosophy teaches one way. And
then if you really start to peel that onion back, though,
over half of our drugs come from botanicals. And then
you start to ask yourself, well, how could Chinese traditional
(29:16):
and aromatic be wrong if they've done this for millions
of years before there was our traditional medicine? So I'd
like to say we should be a little bit less
arrogant about what we teach. Teachers, though, will want to
be experts in what they're teaching. And so if they
what I find is if they don't know enough about
(29:37):
those other types, they have a tendency to just blow
them off. And the approach I take is don't blow
them off. You're going to find out a lot about
your patients. If you're open minded to whatever it is
they are doing, just ask them, Do you take herbs?
Do you take supplements? And don't be arrogant about it.
It's okay to say, Well, I don't know if that's
(29:58):
helpful for you. I learned a long time ago and
bought the Physician's desk reference has an herbal PDR for
herbals and things so that I could be a better
doctor for my patients because one out of two adults
take some sort of supplement or vitamin and you might
as well be open to it.
S1 (30:15):
It can feel intimidating or shaming. If someone meets that
with arrogance, it can be embarrassing. Let me ask you this.
This this isn't really Eastern or I don't know what
this is, but what do you think about Colonic people
who go get colonics?
S2 (30:28):
Yeah. So I think that's Russian roulette in the aspect
that because we don't know all those billions of bacteria,
we do know that people are healthier if they have
a high variety and a high complement of them. So
folks that have had gut surgery to remove parts of
their intestines have less bacteria and they have more issues.
(30:49):
People who have been on antibiotics are much more prone
to getting other gut infections like C difficile. So I
think messing with your gut bacteria is a bit of
Russian roulette. Now, I will tell you as an interesting side,
there are a few of my patients who say that
when they come for their colonoscopy every ten years, that
(31:10):
they feel better than they felt because they've washed their
bacteria out. You reconstitute, though, very, very, very quickly. So
I think they may be constipated people. And the wash
out got rid of the £6 of poop in there. Oh.
S1 (31:25):
God.
S2 (31:25):
Which is about what the average person is carrying around.
S1 (31:28):
For real? Yeah. £6. And that's. I knew. I did
not know that. So your face.
S2 (31:36):
There, there was a really neat speaker that came to
one of our seminars and he taught me a lot
in one lecture about microbiome and he had a study,
some guy every single day quantified and did this PCR
testing for the speciation of his stool. So it was
(31:56):
persistent in a 360 days of the year, except for
the couple of times he got a cold and then
it changed. So it's hard to alter your microbiota. A
lot is is true. And just washing it out every
once in a while probably won't hurt. But I'm not
one to say that it necessarily would help.
S1 (32:15):
Do you do a lot of those fecal transplants?
S2 (32:17):
We've done them since 2012. It's an amazing fantastic cure
for refractory C difficile when the antibiotics have failed and
every course of antibiotics to try to get rid of
C difficile, then you're wiping out other commensal. Right? That
might be helping the process. So it's very rewarding to
be able to do a fecal transplant on someone who's
(32:39):
nearly on death's door or is on death's door. I've
done them in people in the ICU who are on
pressors and they get better. And that's not not all
of them, but it's a very rewarding thing to do.
S1 (32:52):
Can I ask you about Ozempic? Is that part of
your practice? What is that? Oh, it's like the most
popular trending gone viral thing on the planet. Oh.
S2 (33:02):
Yeah. So is medical treatment for obesity that is gained
in popularity. Some of the ways it works is that
it actually makes you feel full really quickly. It can
give you what we call gastroparesis so people feel satiated.
That's one of the ways that it works. So what
will will emerge are a variety of. Drugs that affect
(33:26):
your insulin levels. So there will be a variety of
of drugs that work to help metabolic syndrome, which is
abnormal insulin response and then others that will like make
you feel full so you don't overeat or the surgical
procedures sleeve procedure is going to be pretty popular. I
(33:48):
saw a recent article about sleeve and gastric bypass and
how they're probably going to be done more often because
of our no pun intended growing problem with obesity. So
the drugs right now are very expensive and a lot
of people can't get them.
S1 (34:06):
Can you talk about the obesity problem in America?
S2 (34:09):
Yeah, I think it's so multifactorial that it's just not
one thing. I mean, like in the 70s when we
were at Cold War is where you started to really
see like teenage obesity rates go up while we all
drank soda pop and it had high fructose corn syrup,
we didn't know that that was bad. He said, Well,
it's a sugar, okay, but if you're not utilizing that,
(34:31):
if you're not like in the middle of a workout,
your body doesn't treat high fructose corn syrup the same
way it treats other sugars. And so it will skip
the Krebs cycle and it'll store it as fat. So
in the 70s, we were in Cold War with Russia
and the American farmers stopped exporting corn. Russia had been
dependent on us at that time is the way it
(34:52):
was explained to me.
S1 (34:53):
It's fascinating.
S2 (34:54):
And so what did we do? We had all this
corn and we said it's pretty stable. You know, we
can put it in ketchup instead of sugar because we've
got all the corn, Right? So everything started having high
fructose corn syrup.
S1 (35:06):
Well, it's fascinating how like one cog, though, turns.
S2 (35:08):
I mean, that's just one thing. Of course. Of course.
One thing. And then we can talk about sedentary hours again. Technology.
It's always a double edged sword. There's great technologies out there,
but I'm not sure every five and six and seven
year old needs to spend 4 hours or 5 hours
sitting on their behind with their Gameboy and Xbox and.
S1 (35:31):
All of that. Well, and so much processed food. Now,
does obesity increase your risk of colon cancer?
S2 (35:37):
It definitely does. Now, we haven't figured out a prevention
strategy for a while. We thought aspirin was good. Then
that's been thrown out, that aspirin would be preventative. I'm
actually thinking that vitamin D is going to also come
into play because there's a higher rate of people with
vitamin D deficiency, colon and breast and prostate cancer. So
(35:59):
and those are three very common cancers. And as mentioned earlier,
vitamin D deficiency is very common. So some people say, ah,
that's you know, you're just putting two common things together
and say they're causative. But I think that we're going
to be able to develop studies that would show that
vitamin D will be important for reducing your risk. So,
(36:22):
you know, weight itself, there's a slight increase of all
cause cancer, as is heart disease, hypertension, diabetes. The hard
part then becomes when does it become metabolic syndrome, etcetera.
And you know, what's the real culprit there? So it's multifactorial,
your cancer risk, you know, we know for like bladder
cancer that smoking is a high risk for that one.
(36:46):
But there are people that get bladder cancer that don't smoke.
So are there toxins in the water? And so we're
starting to look harder at the world, not just what
we put in our mouths, but what's in the air,
what's in the water, what's in the.
S1 (36:58):
Soil and plasticizers. I'm like freaking out now and I
drink my water.
S2 (37:01):
I'm glad you brought that up. One of the researchers
at the university, Shirish Barve, he taught me a long
time ago about plasticizers, and he did it by explaining,
You are born with your genetics. And then there's this
thing called epigenetics, which are environmental things that can alter
the gene expression. So taking two identical twin sister mice
(37:26):
and he feeds one of the sisters with a plastic
baby bottle, same amount of calories as his other sister.
What happened to her? Her hair changes from the brown
to like a white. She gets slow and she becomes obese.
That's the only thing that he manipulated in the environment.
Not the number of calories, not the type of food,
(37:46):
but the delivery agent in the plastic bottle. So, you know,
you'll notice in Myers and all the grocery stores and
things that they're going away from selling plastic bottles now,
water that you drink on the shelf, they're going to
sell it in plastic bottles. But the theory here is
don't have it in the backseat of your car and
have it heat up because that might be where the
(38:08):
chemicals might get into the water.
S1 (38:09):
Well, like, how do you know it wasn't heated up
on the delivery bus?
S2 (38:12):
Well, I don't drink bottled water, to answer your question.
But that's an important lesson, though. I do teach that
we're moms, right? We're busy. We make spaghetti sauce and
then we freeze it because we have leftovers. So we
put it in our little. Up or where. And then
we get it out and we stick it in the microwave.
And then what happens to the color of the Tupperware?
S1 (38:32):
Orange.
S2 (38:32):
It turns orange. That means if stuff is getting in
those micro pores in that Tupperware, if pigment can get in,
then you best better realize that that's a good thing.
You can actually freeze it in the Tupperware, but you
should cook it in glass.
S1 (38:46):
So it's the heat that's really breaks it down. Is
that probably.
S2 (38:49):
Yeah, it's probably the heat. And so if you're going
to buy your teenage daughter a water bottle, get one
of those metal ones, Stanley Cup.
S1 (38:56):
What they're called. Yes. So we also tried to like
always give some pointers for all comers that could be
listening to the podcast. So what I'd like for you
to do is go over the colon cancer screening guidelines
for all listeners, and then I want you to talk
about that ridiculous commercial of the poo in the box
and sending it in if you can't get a colonoscopy.
(39:16):
And is that helpful?
S2 (39:18):
Anything you do is helpful. Okay. So first off, colon
cancer is an age related risk. If you live long enough,
one out of ten of us will have colon cancer.
Probably it's a breakdown of your microbiome or your surveillance.
As we age to explain why it's age related or
(39:39):
a buildup of toxins or a reduction of nutrients. So
that's probably why it is age related. So we used
to say, let's start at age 50, do a full colonoscopy.
If you have no polyps, then you can go every
ten years. And the reason we say that is because
it does take time for a polyp to grow up
and become a bad guy. And most of them don't
(40:01):
become bad guys. But most colon cancer starts in a polyp,
and a polyp kind of looks like a little piece
of cauliflower hanging off the wall of your colon. It's
almost like when you get moles on your skin. It's
extra tissue. Why is it there? Why is it paying
attention to the normal, you know, growth pattern here? If
once a polyp is more than two centimeters, that's less
(40:21):
than an inch. 50% will have a focus of cancer.
But if you can remove that polyp, you've cured that
person of the cancer. It's a problem when the polyp
grows and grows down into the wall and through the
layers of the colon, and then it can metastasize to
other areas, lymph nodes, liver, etcetera. So we like to
get there ahead of time and identify people who make polyps.
(40:44):
And if you're a polyp former, even though we've never
figured out exactly why people make polyps, we're going to
survey you more often. And that's when the recipe is
individualized to the patient. It'll depend on the number and
the size that we see, etcetera. Now, today, we know
cancers are occurring earlier. That is true. The new age
is 45 and that's for everybody.
S1 (41:04):
It is true that colon cancer is in the rise
in young adults.
S2 (41:08):
It is true.
S1 (41:08):
And is it safe to assume this is because of
all the other things we've discussed, obesity and nutrients and diet?
S2 (41:15):
I think so.
S1 (41:16):
I mean, there's no reason like it's not like it's
on the rise because of X, It's just on the rise.
We can suspect at this point it's lifestyle related. If
you have a family history. Different, different, of course.
S2 (41:26):
Now, if your grandmother had colon cancer when she was 85,
that probably does not convey a risk to you. So
when we take somebody from being, quote, average risk to
high risk, there's an algorithm that basically you could use
the what we normally say is the index case, like
maybe it was your mom. If she had it at 40,
(41:47):
then you're supposed to have your colonoscopy at 30.
S1 (41:50):
Just like breast.
S2 (41:51):
Screening, ten years younger.
S1 (41:52):
Years prior in the.
S2 (41:53):
First case, if it's a first degree relative.
S1 (41:56):
I got my first colonoscopy after I heard you speak
last time. So he motivated me and it took me
four months to get it.
S2 (42:02):
So you're a good girl.
S1 (42:05):
You inspired me. So maybe you'll inspire some others now
because it is on the rise. Like you hear things
that are on the rise with cancers and things and
you just don't always know. But I think I've learned
a lot. So what we ask our guests at the
end of our talk is in sort of airline terms
or flying terms, Where would you describe your current course
of your life flight right now?
S2 (42:26):
And I have to use the airline. Well, not.
S1 (42:28):
Specific. You don't have to, but just bonus points if
you get in a flying analogy.
S2 (42:33):
Yeah, well, I would say that I'm still up there
in the atmosphere flying around and still learning and still looking.
I'm not ready to land. I am flying around and
I'm enjoying it.
S1 (42:46):
Oh, God, that's so wonderful. And you're healthy. I mean,
we never really said that specifically, but in terms of
the cancer.
S2 (42:52):
I am now.
S1 (42:53):
Yeah, I'm.
S2 (42:54):
I'm 13 years out.
S1 (42:55):
And yes, that's wonderful.
S2 (42:57):
I take much better care of myself. My daughter was
right that I ate well. But I didn't know about
vitamin D. That was the only thing I think that
might have been a key. And I was I was
ignoring the stress, and I was hiding that from a
lot of people. Now, I don't take any drugs for
my stress. I don't need to because I have my bicycle.
S1 (43:21):
Oh, it's a perfect way.
S3 (43:22):
To end the cycles of your all those.
S1 (43:24):
Cycles of your life. Mean you've overcome hard things. I
want to say one more thing. I just thought I
think this is also such a lovely hour of testament
to your mom. I don't know if she's still alive
or not. You didn't say she is. What a guiding
force that you had in your mother. I mean, we're
trying to be a good mother, so we're here to
our younger kids. But just hearing you talk about watching
her go to work and I just I love that.
(43:45):
So thanks for sharing that on the family dinners. This
is really touching the image of that. Thank you. Dr. Kruger,
thank you so much for being with us, Sarah.
S2 (43:52):
Erica, Thank you. It was fun. Good. I enjoyed it.
S1 (43:55):
Thank you. Good. Thanks, Erica. And I want to say
thank you. We just completed our 21st podcast episode. Thank
you to all the listeners, all the shares and all
the feedback. We're toasting and celebrating 21 episodes and the
wrapping up of a series. Stay tuned for possible future
exciting changes. Please be advised that the information discussed on
this podcast is not professional therapy. If you are triggered
(44:19):
or activated, please don't be afraid to seek professional help and.
Welcome back to Connections in Flight. I'm Erica. I'm Sara.
Join us as we have another meaningful conversation about navigating
our current life flight. There are. Yes, there's a big
water bottle. Yeah. I'm drinking that on purpose because of
our guest today. I had the crappiest lunch. Like, I'm
just going to say Pop tarts are involved. So I
(00:23):
was like, Get ready for the podcast. And I was thinking,
Oh my God, I'm gonna like, at least hydrate and
flush out. Hopefully my lunch. We can't be perfect all
the time. No, no. So today we have a really
stellar guest. Her name is Dr. Christine Krieger. She is
a professor of medicine, chief of Academic and Clinical Affairs
(00:45):
in the Division of Gastroenterology and Hepatology and Nutrition at
the University of Louisville. She's pretty much a rock star
over there. She went to the University of Florida School
of Medicine. She gave me some of her college activities.
And it says she was in the circus. I saw that.
I've got to find out what that was. Well, I
knew and currently, besides working full time, having a lot
(01:08):
of interest and of course, gut microbiome.
UU (01:11):
Alternative pathways of healing. Got all of that.
S1 (01:16):
Her most proud moments are the fact that she's a
mother to a daughter who's a veterinarian and a son
who's an engineer and a chef. She does sprint triathlons,
but she's very athletic, obviously, which leads to her word,
which is cycle makes so much sense. I can't wait
to hear how she talks about it. But no, you know,
when I think of our life cycles in seven years
(01:38):
and gut biome and microbiome and yeah, I mean, I'm
jumping the gun here, but I have heard her speak
before with you and I just I feel like every
time she says something, I learned something new and I
think about it for a long time. Yeah. I've actually
had her speak twice at those health salons, and people
just can't get enough of what she says. And honestly,
(01:58):
this would be my third time speaking with her in
a similar format. And like you said, I just always
learned something new, so. Well, let's go. All right. Thank
you to Betterhelp for sponsoring this episode. Betterhelp is the
world's largest therapy service and it's 100% online with Betterhelp,
you can tap into a network of over 30,000 licensed
(02:19):
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That way, Betterhelp can match you with the right therapist
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(02:39):
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(03:02):
Com slash connections and flight. That's better. Capital b e.
T e. R h e lp slash connections and flight.
Welcome to the podcast. Thank you very much. Erica and
I are so happy to have you here. We'll just
start as we start with most of our guests and
just tell us like where you grew up, where you're born.
S2 (03:23):
Well, I was born in Texas. My father was an
Air Force pilot. And I think I moved 11 times
before going to college. I got used to being the
new kid in the class and had to learn how
to open my mouth. So I very much enjoyed moving
all over the country. When my father went to Vietnam,
(03:45):
my mother, unbeknownst to me, had been a nurse. She
had been taking care of me and my sister, and
I didn't even really realize that she'd had a career
that she put on hold. So when Daddy went to Vietnam,
mom went back to work and we didn't know if
we would ever see him again. But she would come
home and say these wonderful things about what she did
(04:07):
in the operating room and what they did for patients.
And that's actually when I knew I was going to
go into medicine. I was 12 years old.
S1 (04:17):
Wow. So you were 12 when your dad went to Vietnam? Yeah.
Do you mind if we ask how old you are
right now?
S2 (04:23):
I'm 63. I'll be 64 in December. All right.
S1 (04:27):
You're wearing 63. Very well. Thank you. Let me ask you,
did you see your dad again? Yes. Oh, thank God.
S2 (04:34):
I know. I mean, it was a time there were
no cell phones. So we would wait for these little
eight track tapes. And I remember having some monetary dreams
where I knew something bad was happening. His barracks got bombed,
his best friend didn't make it. And I had a
dream about it. Told my mom even before the tape came.
So there's that kind of. Yeah, you know, weird energy. Yeah.
(04:59):
Across the Oh.
S1 (05:00):
We talk about energy a lot, so we totally believe that. Yeah.
S2 (05:04):
But no, daddy came home and we continued to move.
And then in I think it was in Omaha, Nebraska,
where I graduated from high school, my sister got recruited
on a swimming scholarship to Florida State. And I followed
her because at that time I wanted to be with
my sister. And that began living in Florida and going
(05:24):
to medical school. And that's how it all began.
S1 (05:28):
What year did you graduate medical school?
S2 (05:30):
In 1985.
S1 (05:31):
Wait, wait, wait. I have a question. Before medical school.
The circus. Oh, we promised. We want to talk about
the circus waiting. Oh, that's in your bio. Thank you. Like,
Wait a second. We have got to know what that
was about.
S2 (05:44):
So Florida State University has a circus that is a
I think it's a varsity sport now. And it doesn't
have animals and clowns and things like that. But it
had intense acrobatics. The trapeze I was too tall to
be a a flyer, as we call the girls, but
I still get to participate in all kinds of different activities. Juggling,
(06:08):
walking a wire.
S1 (06:10):
Hi.
S2 (06:10):
My gosh. And my act was over a net and
I never broke anything. We didn't do it without nets,
but I never even fell during an act so that
it was extremely fun. We did all the rigging. When
we would go around, we traveled a little bit. We'd
have to put the nets up and take them down.
We made our own costumes. It was a really neat
(06:33):
time and amazing.
S1 (06:35):
I have never met anyone who says I was in
the circus. Yeah, that is fantastic. What a awesome college
kind of pastime. I think it sounds amazing. I'd love
to be on the trapeze. So you were in the
circus and you got into medical school. You graduated medical
school in 1985. Tell me about mid-eighties being a woman
where you like, I'm going to be a GI doctor then,
(06:55):
or did you wait or did you go straight to fellowship?
S2 (06:57):
Well, after medical school, then you do what's called a residency.
And I remember the first years, your internship year, and
then you get your medical license as soon. I mean,
it was July 2nd of the next year. I had
my license and I moonlit a lot in order to
pay my loans. And Moonlighting showed me the emergency room world,
(07:21):
which I thoroughly loved. So as I was then, now
a resident, I continued to do emergency medicine all throughout
my residency, even into my GI Fellowship. There were no
workout restrictions back then, and so you could work as
much when you weren't in your training, which was great
because I was able to pay all my loans off.
S1 (07:41):
Were you doing an internal medicine residency and moonlighting in
the E.R..
S2 (07:45):
And moonlighting in various emergency rooms around the area and
loved it. And I was in my fellowship for GI
at the time, but I didn't want to give up E.R.
but I decided that I liked them both and that
I didn't want to have to do another E.R. residency. So.
S1 (08:01):
So you hit the GI tract straight out.
S2 (08:03):
My first academic job was Mobile, Alabama, very small clinical
focus group. And from there I moved to UK in
97 to 2000 when you of L built the digestive
health center and I was asked to be the director there.
About nine of us came over from UK.
S1 (08:21):
Tell us about kind of your more adult life than
you were working you were married.
S2 (08:26):
So I'm I am now remarried. The father of my
two children. He also moved up to UK. And shortly thereafter, though,
our relationship fell apart. Sometimes a therapist will tell you
it'll take five years to figure out what happened. And
I think that's true. And you finally come to the
grips of what was wrong with you, what you could
(08:50):
have done to keep that relationship going. And you finally
then learn a lot about yourself. So hopefully then you
don't make those mistakes again. I decided with a full
time job that I would raise my kids pretty much myself.
They were five and seven, I think, when we broke
up and I became probably the dark part of my
(09:11):
life that next ten years because. I thought I was invincible.
I thought I could do it all and fill in
all the gaps. And I think my stress really, really, really,
really accelerated. And that eventually led to a health problem.
S1 (09:30):
I'm curious, did you reflect on your mom having to
step back into work when your dad was gone? Was
that a helpful kind of role modeling for you during
that hard time?
S2 (09:40):
Yeah, well, my mom was the strongest lady I know.
She's a little pistol, but she's strong and she's somebody
I talked to every day. So I constantly had help
and encouragement. She's a very positive individual. I got strength
from her. But I it was at at the expense
(10:00):
of my own health. And I know I don't think
my kids suffered. I was fortunate enough to be able
to hire some people to pick them up after school,
to take them to their sporting events. That was challenging,
to find people that only want to work part time,
you know, every day from 2 to 6 or something.
But it worked. I'm happy that from a health standpoint
(10:23):
that I always managed to have sit down and dinners
with my kids. We did very little fast food. Dinnertime
was special, as it was with my mom that we'd
sit at the table and we didn't say bad things
about school or anything. It would be what was the
best part of your day. And I really think that
holds families together to have a time where you're sharing
(10:46):
like good food and you're also talking about positive events
of your day right now.
S1 (10:52):
Well, here you are working with the children. And what happened?
S2 (10:56):
I felt a breast lump when we were on a cruise.
And I remember that my kids were now teenagers and
they didn't want mommy to be taking pictures of them anymore.
And I was still very, very much wrapped up in
their lives. I felt that lump and it was like
August and. I ignored it. And I don't know why.
(11:19):
I really don't. In December, I decided to do something
about it because it felt different from a cyst. It
didn't hurt. It. It just felt like it wasn't part
of me. And so I got it evaluated and I figured, well,
maybe it's just fibrosis stick stuff. I've had that before.
And when the biopsy came back positive, I remember the
(11:41):
phone call from the very nice guy that did the
biopsy and he said, I can't believe I'm telling you this,
but it's cancer. So. I told my children the time.
My son was 15. And I just met a really
wonderful man. I did not date, literally. Like, maybe that's
(12:04):
why I went and had the biopsy done. Literally, it
was like a month before that I met a very
nice man. My son's response as a typical 15 year
old was, Is your boyfriend going to dump you? And
I and I said, Well, if he does, he's not
the right one. But what's etched in my mind forever
(12:25):
and Make me cry was when I told my daughter
and my daughter, Lips started trembling and she said, But Mommy,
you do everything right. After I went through surgery and
all of that, I read a lot about breast cancer.
And we don't talk about when girls were sports bras.
(12:46):
They crush their breasts. That's injurious. The other one was
it was emerging to be very curious about the vitamin
D connection. And I went ahead and I checked my
vitamin D level and it was below the recommended amount
of 30. I believe the range is really high, 30
(13:08):
to 100. I've since learned and taught you really want
to level around 50 or 60, and it might be
hard for people to get there with sunscreens and the
ozone layer and whatnot. But I truly believe and so
do endocrinologists believe for bone mineral density and sports physiologists
for muscle recoil cycling that and psychology. Mood and mood, mood. Huge. Erica,
(13:35):
there have been a few of my colleagues that bring
their kids to me. I'm not a pediatric GI doctor
but that have some GI illnesses and they maybe are
18 or 19. And I look at these kids and
they're inside all the time on their games and they're pale.
And I say, you probably have a low vitamin D level.
And they did. I mean, I've had like a handful.
(13:57):
And with giving them a supplement, they don't have to
take their mood medication anymore. So yeah, I think vitamin
D is a big story. And women who want to
reduce their risk maybe have their primary care doctor check
them and that might be a strategy in the future.
S1 (14:16):
I have like a lot of things I want to
get to the vitamin in the health changes that you
may have made after your diagnosis of cancer. But I
do want to stay on this one topic of, I guess, denial.
And I'm just curious to kind of go down this
rabbit hole right now because I am a breast radiologist,
so I do breast biopsies and you do talk to
so many people who are like, I knew it was there,
(14:37):
you knew it was there, but like you didn't act
on it. And I'm just wondering if we can talk
a little bit about that right now. Like, what do
you think about that, Erica? I think denial is exactly
you're denying the fear of what if I am vulnerable, Right.
You said here here you had all of this, these
things you've overcome. It's almost like it can be subconsciously
(14:59):
avoiding the fear. It's so interesting what I mean, if
someone's listening and thinking, Oh, I have a whether it
be a lump in the breast or something else, that
just I love what you said. It just didn't feel
part of my body. No, it didn't. And that I
think that is so key. Like just body self awareness
because so many lumps and bumps that we have, they
are normal, like you said. But when something doesn't feel right,
it doesn't feel like me. That's definitely a signal. What
(15:21):
do you think are some questions or maybe some self
talk a woman could do right now if she thinks
she has a problem somewhere and is kind of stuck
in that denial?
S2 (15:29):
Well, as you too are talking about that, I reflected
on that. And for me personally, I was depressed. So
it's interesting. You talked about mood and vitamin D, and
I had never been diagnosed with any depression. I really
didn't even consider myself depressed, but I was depressed. When
(15:51):
I look back at the couple of years prior to
my diagnosis, I stopped really taking care of myself. I
didn't really exercise. I never really carried a lot of weight,
but I wasn't in very good cardiovascular shape. I think
the depression is what people don't label necessarily, and then
they get in that vicious spiral. And I do think
(16:14):
there's a significant link to a lot of cancer and depression.
So I guess what I would say to people is
the flip side is you can be cured. There are
fantastic cures. So, you know, I'm not going to say
it's easy to get over your fear or to snap
out of it or change your mood or, you know,
(16:35):
because those things take time and reflection on all of that.
The night I had my bilateral mastectomy and the reason
I had bilateral is because there were issues on the
other breast two, and they told me that they would
have to like look forever. And yeah.
S1 (16:50):
You don't have to defend having a bilateral. I support.
S2 (16:52):
That. Yeah. So but I remember the nurse that night
just how fantastic she was and how caring she was
because I had these drains and stuff and she was
just really careful not to cause me any pain when
she put the pillows and everything. I mean, people were
so wonderful after the fact. They were not pejorative. I
didn't feel stigmatized at all. They were fantastic.
S1 (17:16):
Did your depression worsen while you're undergoing treatment for cancer?
S2 (17:20):
Here's the funny thing. I remember telling a dental hygienist,
You know, I turned 50. Fell in love and got
breast cancer. I changed my mood. I started taking care
of myself. I had felt the support and love around
my new boyfriend. When he found out I was going
to drive myself to the hospital for my bilateral mastectomy.
S1 (17:43):
And of course you were.
S2 (17:44):
And. And I was. And he said, I will break
both of your knees. You do that. And it was
me just realizing that you have you're the one that's
going to find this. You're the one that's going to
take care of it. And most women find their own
breast lumps. It's great to have screening, but most women
find their. Yeah, if it's palpable.
S1 (18:06):
What are some changes that you made to turn your
health around?
S2 (18:10):
I started cycling. Oh, hear that word.
S1 (18:15):
How did that come into your life?
S2 (18:17):
With my new beau. After the surgery, you know, we
were in a bike store and on a lark, he
was very interested in bikes, and we decided we'd buy
these bikes. Now, I had had an orthopedic injury to
my neck when I was in the.
S1 (18:32):
Circus and all that.
S2 (18:33):
So, you know, the only thing I ever had wrong
was that I'd had some c spine disc herniations, you know,
for being too crazy. When I was young, I didn't
know whether I would be able to do the bike,
but we went ahead and we bought the bikes and
we have never looked back. I can tell you I'm
sitting in this room looking at your airplane and all
(18:55):
of that. There's something about cycling that's hard to explain
why it means so much, but it's freedom, it's exploration.
It's what's around the next corner. It's meeting new people,
seeing the world in a different way and in a
subtle way.
S1 (19:11):
What else do you think helped with the Depression? Did
you get any other. Really avid learning about vitamins because
the vitamin industry I mean, forget it. It's not regulated.
Nobody really knows. You don't know what time of day
your levels are drawn. You don't even know what the
range is from 0 to 1 million. Like, yeah. Can
you give us some?
S2 (19:29):
Sarah I probably read 200 articles to give one lecture
that a colleague asked me to give. I was very
nervous because it was to a group of dietitians. Oh, wow.
And those ladies know their stuff. Yeah, they do. Right?
They're the real experts. So in order to prepare for
that lecture, I read a lot, a lot of scientific
literature refuting, Do you really need vitamins, get older? Or
(19:52):
what stood out consistently in the United States is two vitamins.
One vitamin D is probably across the world as well,
that a third of us will become vitamin D deficient.
And then the next one, I don't know if you'll
guess it, but when I was cycling, I was starting
having cramps. And it's not the potassium.
S1 (20:14):
Magnesium, it's.
S2 (20:15):
Magnesium. That's right. And so then I because I had
to do this lecture for my colleague friend, I had
already started taking magnesium and my cramps got a lot better. Seriously,
it was amazing. But here's the hard part about magnesium
because we've got such strong buffer systems, the majority of
(20:36):
your magnesium is in your bones. And so that's back
to bone mineral density. It's calcium, vitamin D and magnesium
that make the the bone very, very strong. So when
you become deficient, you don't know it because you're just
eating it out of your bones. And so your serum
levels look normal. So it's very difficult to diagnose.
S1 (20:59):
Very. And you're talking about osteopenia, osteoporosis.
S2 (21:02):
Osteopenia, osteoporosis and and rampant. Right, right, right. So you
almost have to just supplement.
S1 (21:10):
You're saying supplement preventatively preventative. Yeah.
S2 (21:13):
Because. Interesting. Yep. And the only people that shouldn't and
you obviously should talk to your doctor about it, but
people with kidney issues, they may have to reduce their
magnesium intake, but for the majority of people, magnesium can
be a safe supplement. There's a range, you know, 200
to 400mg. Not all the magnesium are the same.
S1 (21:35):
Let me ask you, for women like Eric and I
were both. How old are we, Erica? We're for 47.
For 47, would you say take magnesium, calcium, vitamin D?
S2 (21:45):
Yeah, I definitely believe in and doing all that reading.
Those were the two that stood out. And there's reasons,
some of the reasons for magnesium deficiency, which is even
a little more common than vitamin D deficiency, is the
water softeners, hydroponic growth, vegetables instead of in the soil,
and then over use of the soil in the farming
(22:06):
industry where the magnesium comes from. So it comes from
vegetables that grow in the ground and we get it
that way. But if the soil is poor, then the
magnesium quantities have gone down. So yes, I recommend when
people say, what should I do? I will ask about
their diet and make sure they're eating fruits and vegetables,
(22:28):
which makes it easier today when we know that plant
based diets are probably the best diets for us. It
doesn't mean you can't ever eat meat. That's not the
same thing. But eating fruits and vegetables that grow out
of the ground provide most of all of the nutrients
that you need with the exception that you might not
get enough magnesium and you might not get enough vitamin D,
(22:50):
Do I think people need to calcium supplement?
S1 (22:53):
I don't. I've heard that from my doctor as well.
How come?
S2 (22:57):
I guess part of it is a lot of people
have side effects from it and then I think they
eat enough dairy and enough green leafy vegetables for the
most part that they're not as deficient. Again, endocrinologists who
I very much respect at our university, if someone has osteopenia, osteoporosis, obviously,
(23:20):
then they're going to put them on it. I guess
the question is, if you don't have those conditions, should
you supplement, will that help prevent it? And I'm not
the expert there. I we'll find out.
S1 (23:32):
I do want to know, though, when you're talking about
kind of prevention versus how you know, when your gut
isn't healthy, great. Like I know the word microbiome is
floating around with everybody. And how do you know if
your microbiome is healthy? How do you know what to change?
S2 (23:48):
Yeah, loaded question Emerging science. And I think the more
I learn about it, the more I know there's more
that needs to be learned. I do know that your
gut actually tells you what to crave, and that might
be a bad thing if it tells you to crave.
S1 (24:05):
Pop Tarts and Doritos.
S2 (24:06):
Pop Tarts activities or other highly sugary foods. I mean,
there are mice that will be driven to drink alcohol
if they have a certain gut microbiome. So we're unraveling
those mysteries right now. I think I can look at
somebody and to the point where I can look at
someone and say they probably have a healthy microbiome because
their body habitus is more normal, their muscular tone is
(24:31):
more normal, they have less illnesses. I think we're going
to find a lot of illnesses that are related to
the microbiome being out of whack.
S1 (24:40):
Are you born with your microbiome?
S2 (24:42):
Well, your first introduced to bacteria when you're born and
your gut will become colonized. I mean, moms know their
newborn babies don't have normal poop yet and they don't
start having normal amounts of bacteria until they're exposed to
the world, your genetics you inherit, and then you get
(25:04):
the bacterial colonization of your skin and your gut and
everything in your house.
S1 (25:10):
So your microbiome is the lining of your gut. Is
that what we're talking about?
S2 (25:14):
It's not just the lining of the gut, it's the
bacteria and the multiple types of bacteria that are in there.
I mean, there's other things, there's mucin and stuff like that.
But the microbiome is really the microbes. We're we're using
sophisticated technology to class them into big classes. But there's
(25:34):
also a very unknown world of the amounts of viruses
and funguses that are in there as well. So again,
this is a huge field that we don't know a
whole lot about, but we're a lot of people are
highly interested in it. I like to teach that there's
ten times more bacteria inside your gut than there are
(25:58):
cells in your entire body. Oh, wow, what? Ten times more.
And so you better be in harmony with your gut bugs.
S1 (26:08):
And so with a probiotic, which is what so many
people are recommended, how do you know which type to take?
S2 (26:14):
You don't it's not regulated. They're not all created equal.
There's probiotics and prebiotics prebiotics help gut microbes, feed them
like a yogurt. You can take yogurts, which they they'll
advertise they're rich in probiotics. They're right. But here's a
couple of little tips. Don't drain the liquid off of
(26:36):
your yogurt. That's where all of the bacteria are. They
are good for most people. But if a patient tells
me they don't like one particular kind, it upsets their stomach.
Then I say, Well, then try something else, because I
am not going to pretend to be able to guess
in those billions of bacteria and where that person has
traveled and all of that, what particular one is right
(26:58):
for them. Now what I will say is being a
generalist here in this topic, the more variety you have,
the better. So if you were wanting to get a
higher quality yogurt, for example, you would look for the
one that has more species and there's two like major
kinds of probiotics, the lactobacilli acidophilus type help, the upper gut,
(27:23):
and then anything that starts with bifidobacteria helps the colon.
So you want something that's really rich in all of it.
If you ever find a yogurt that has Bifidobacteria Infantis
that's a really good one.
S1 (27:36):
Infantis. Yeah, heck yeah. I'll be looking for that one. Yeah.
Do you tell patients to take probiotics? Well.
S2 (27:43):
Remember, my patients are coming having probably gone through their
primary care doctor and then they've got something wrong with
their gut and it's a bit of a workup to
make sure they don't have an organic illness. They don't
have a food allergy, they don't have hidden celiac. We
talk about what our stools are supposed to look like
and how often and that sort of thing. And it's true,
(28:05):
men are lucky. They have usually one formed bowel movement
a day. Women are lucky if they have one every
other day. Is the average. The medical definition of constipation
is when you don't have a bowel movement in 72 hours.
So I'll get a lot of patients that are swinging
one way or the other or back and forth. And
(28:26):
then if I find out they've been on antibiotics, right.
That interfered, then those are the ones that I say
you might try probiotics.
S1 (28:35):
Point It's so complicated. And I think that there's been
a lot more mainstream talk about functional medicine. Where are you?
Do you feel torn about conflicting opinions about that? Do
they work together Well, What's where are we in the
world of all of the information out there?
S2 (28:53):
I have always, always been interested in other ideas, recognizing
that our Western medical school philosophy teaches one way. And
then if you really start to peel that onion back, though,
over half of our drugs come from botanicals. And then
you start to ask yourself, well, how could Chinese traditional
(29:16):
and aromatic be wrong if they've done this for millions
of years before there was our traditional medicine? So I'd
like to say we should be a little bit less
arrogant about what we teach. Teachers, though, will want to
be experts in what they're teaching. And so if they
what I find is if they don't know enough about
(29:37):
those other types, they have a tendency to just blow
them off. And the approach I take is don't blow
them off. You're going to find out a lot about
your patients. If you're open minded to whatever it is
they are doing, just ask them, Do you take herbs?
Do you take supplements? And don't be arrogant about it.
It's okay to say, Well, I don't know if that's
(29:58):
helpful for you. I learned a long time ago and
bought the Physician's desk reference has an herbal PDR for
herbals and things so that I could be a better
doctor for my patients because one out of two adults
take some sort of supplement or vitamin and you might
as well be open to it.
S1 (30:15):
It can feel intimidating or shaming. If someone meets that
with arrogance, it can be embarrassing. Let me ask you this.
This this isn't really Eastern or I don't know what
this is, but what do you think about Colonic people
who go get colonics?
S2 (30:28):
Yeah. So I think that's Russian roulette in the aspect
that because we don't know all those billions of bacteria,
we do know that people are healthier if they have
a high variety and a high complement of them. So
folks that have had gut surgery to remove parts of
their intestines have less bacteria and they have more issues.
(30:49):
People who have been on antibiotics are much more prone
to getting other gut infections like C difficile. So I
think messing with your gut bacteria is a bit of
Russian roulette. Now, I will tell you as an interesting side,
there are a few of my patients who say that
when they come for their colonoscopy every ten years, that
(31:10):
they feel better than they felt because they've washed their
bacteria out. You reconstitute, though, very, very, very quickly. So
I think they may be constipated people. And the wash
out got rid of the £6 of poop in there. Oh.
S1 (31:25):
God.
S2 (31:25):
Which is about what the average person is carrying around.
S1 (31:28):
For real? Yeah. £6. And that's. I knew. I did
not know that. So your face.
S2 (31:36):
There, there was a really neat speaker that came to
one of our seminars and he taught me a lot
in one lecture about microbiome and he had a study,
some guy every single day quantified and did this PCR
testing for the speciation of his stool. So it was
(31:56):
persistent in a 360 days of the year, except for
the couple of times he got a cold and then
it changed. So it's hard to alter your microbiota. A
lot is is true. And just washing it out every
once in a while probably won't hurt. But I'm not
one to say that it necessarily would help.
S1 (32:15):
Do you do a lot of those fecal transplants?
S2 (32:17):
We've done them since 2012. It's an amazing fantastic cure
for refractory C difficile when the antibiotics have failed and
every course of antibiotics to try to get rid of
C difficile, then you're wiping out other commensal. Right? That
might be helping the process. So it's very rewarding to
be able to do a fecal transplant on someone who's
(32:39):
nearly on death's door or is on death's door. I've
done them in people in the ICU who are on
pressors and they get better. And that's not not all
of them, but it's a very rewarding thing to do.
S1 (32:52):
Can I ask you about Ozempic? Is that part of
your practice? What is that? Oh, it's like the most
popular trending gone viral thing on the planet. Oh.
S2 (33:02):
Yeah. So is medical treatment for obesity that is gained
in popularity. Some of the ways it works is that
it actually makes you feel full really quickly. It can
give you what we call gastroparesis so people feel satiated.
That's one of the ways that it works. So what
will will emerge are a variety of. Drugs that affect
(33:26):
your insulin levels. So there will be a variety of
of drugs that work to help metabolic syndrome, which is
abnormal insulin response and then others that will like make
you feel full so you don't overeat or the surgical
procedures sleeve procedure is going to be pretty popular. I
(33:48):
saw a recent article about sleeve and gastric bypass and
how they're probably going to be done more often because
of our no pun intended growing problem with obesity. So
the drugs right now are very expensive and a lot
of people can't get them.
S1 (34:06):
Can you talk about the obesity problem in America?
S2 (34:09):
Yeah, I think it's so multifactorial that it's just not
one thing. I mean, like in the 70s when we
were at Cold War is where you started to really
see like teenage obesity rates go up while we all
drank soda pop and it had high fructose corn syrup,
we didn't know that that was bad. He said, Well,
it's a sugar, okay, but if you're not utilizing that,
(34:31):
if you're not like in the middle of a workout,
your body doesn't treat high fructose corn syrup the same
way it treats other sugars. And so it will skip
the Krebs cycle and it'll store it as fat. So
in the 70s, we were in Cold War with Russia
and the American farmers stopped exporting corn. Russia had been
dependent on us at that time is the way it
(34:52):
was explained to me.
S1 (34:53):
It's fascinating.
S2 (34:54):
And so what did we do? We had all this
corn and we said it's pretty stable. You know, we
can put it in ketchup instead of sugar because we've
got all the corn, Right? So everything started having high
fructose corn syrup.
S1 (35:06):
Well, it's fascinating how like one cog, though, turns.
S2 (35:08):
I mean, that's just one thing. Of course. Of course.
One thing. And then we can talk about sedentary hours again. Technology.
It's always a double edged sword. There's great technologies out there,
but I'm not sure every five and six and seven
year old needs to spend 4 hours or 5 hours
sitting on their behind with their Gameboy and Xbox and.
S1 (35:31):
All of that. Well, and so much processed food. Now,
does obesity increase your risk of colon cancer?
S2 (35:37):
It definitely does. Now, we haven't figured out a prevention
strategy for a while. We thought aspirin was good. Then
that's been thrown out, that aspirin would be preventative. I'm
actually thinking that vitamin D is going to also come
into play because there's a higher rate of people with
vitamin D deficiency, colon and breast and prostate cancer. So
(35:59):
and those are three very common cancers. And as mentioned earlier,
vitamin D deficiency is very common. So some people say, ah,
that's you know, you're just putting two common things together
and say they're causative. But I think that we're going
to be able to develop studies that would show that
vitamin D will be important for reducing your risk. So,
(36:22):
you know, weight itself, there's a slight increase of all
cause cancer, as is heart disease, hypertension, diabetes. The hard
part then becomes when does it become metabolic syndrome, etcetera.
And you know, what's the real culprit there? So it's multifactorial,
your cancer risk, you know, we know for like bladder
cancer that smoking is a high risk for that one.
(36:46):
But there are people that get bladder cancer that don't smoke.
So are there toxins in the water? And so we're
starting to look harder at the world, not just what
we put in our mouths, but what's in the air,
what's in the water, what's in the.
S1 (36:58):
Soil and plasticizers. I'm like freaking out now and I
drink my water.
S2 (37:01):
I'm glad you brought that up. One of the researchers
at the university, Shirish Barve, he taught me a long
time ago about plasticizers, and he did it by explaining,
You are born with your genetics. And then there's this
thing called epigenetics, which are environmental things that can alter
the gene expression. So taking two identical twin sister mice
(37:26):
and he feeds one of the sisters with a plastic
baby bottle, same amount of calories as his other sister.
What happened to her? Her hair changes from the brown
to like a white. She gets slow and she becomes obese.
That's the only thing that he manipulated in the environment.
Not the number of calories, not the type of food,
(37:46):
but the delivery agent in the plastic bottle. So, you know,
you'll notice in Myers and all the grocery stores and
things that they're going away from selling plastic bottles now,
water that you drink on the shelf, they're going to
sell it in plastic bottles. But the theory here is
don't have it in the backseat of your car and
have it heat up because that might be where the
(38:08):
chemicals might get into the water.
S1 (38:09):
Well, like, how do you know it wasn't heated up
on the delivery bus?
S2 (38:12):
Well, I don't drink bottled water, to answer your question.
But that's an important lesson, though. I do teach that
we're moms, right? We're busy. We make spaghetti sauce and
then we freeze it because we have leftovers. So we
put it in our little. Up or where. And then
we get it out and we stick it in the microwave.
And then what happens to the color of the Tupperware?
S1 (38:32):
Orange.
S2 (38:32):
It turns orange. That means if stuff is getting in
those micro pores in that Tupperware, if pigment can get in,
then you best better realize that that's a good thing.
You can actually freeze it in the Tupperware, but you
should cook it in glass.
S1 (38:46):
So it's the heat that's really breaks it down. Is
that probably.
S2 (38:49):
Yeah, it's probably the heat. And so if you're going
to buy your teenage daughter a water bottle, get one
of those metal ones, Stanley Cup.
S1 (38:56):
What they're called. Yes. So we also tried to like
always give some pointers for all comers that could be
listening to the podcast. So what I'd like for you
to do is go over the colon cancer screening guidelines
for all listeners, and then I want you to talk
about that ridiculous commercial of the poo in the box
and sending it in if you can't get a colonoscopy.
(39:16):
And is that helpful?
S2 (39:18):
Anything you do is helpful. Okay. So first off, colon
cancer is an age related risk. If you live long enough,
one out of ten of us will have colon cancer.
Probably it's a breakdown of your microbiome or your surveillance.
As we age to explain why it's age related or
(39:39):
a buildup of toxins or a reduction of nutrients. So
that's probably why it is age related. So we used
to say, let's start at age 50, do a full colonoscopy.
If you have no polyps, then you can go every
ten years. And the reason we say that is because
it does take time for a polyp to grow up
and become a bad guy. And most of them don't
(40:01):
become bad guys. But most colon cancer starts in a polyp,
and a polyp kind of looks like a little piece
of cauliflower hanging off the wall of your colon. It's
almost like when you get moles on your skin. It's
extra tissue. Why is it there? Why is it paying
attention to the normal, you know, growth pattern here? If
once a polyp is more than two centimeters, that's less
(40:21):
than an inch. 50% will have a focus of cancer.
But if you can remove that polyp, you've cured that
person of the cancer. It's a problem when the polyp
grows and grows down into the wall and through the
layers of the colon, and then it can metastasize to
other areas, lymph nodes, liver, etcetera. So we like to
get there ahead of time and identify people who make polyps.
(40:44):
And if you're a polyp former, even though we've never
figured out exactly why people make polyps, we're going to
survey you more often. And that's when the recipe is
individualized to the patient. It'll depend on the number and
the size that we see, etcetera. Now, today, we know
cancers are occurring earlier. That is true. The new age
is 45 and that's for everybody.
S1 (41:04):
It is true that colon cancer is in the rise
in young adults.
S2 (41:08):
It is true.
S1 (41:08):
And is it safe to assume this is because of
all the other things we've discussed, obesity and nutrients and diet?
S2 (41:15):
I think so.
S1 (41:16):
I mean, there's no reason like it's not like it's
on the rise because of X, It's just on the rise.
We can suspect at this point it's lifestyle related. If
you have a family history. Different, different, of course.
S2 (41:26):
Now, if your grandmother had colon cancer when she was 85,
that probably does not convey a risk to you. So
when we take somebody from being, quote, average risk to
high risk, there's an algorithm that basically you could use
the what we normally say is the index case, like
maybe it was your mom. If she had it at 40,
(41:47):
then you're supposed to have your colonoscopy at 30.
S1 (41:50):
Just like breast.
S2 (41:51):
Screening, ten years younger.
S1 (41:52):
Years prior in the.
S2 (41:53):
First case, if it's a first degree relative.
S1 (41:56):
I got my first colonoscopy after I heard you speak
last time. So he motivated me and it took me
four months to get it.
S2 (42:02):
So you're a good girl.
S1 (42:05):
You inspired me. So maybe you'll inspire some others now
because it is on the rise. Like you hear things
that are on the rise with cancers and things and
you just don't always know. But I think I've learned
a lot. So what we ask our guests at the
end of our talk is in sort of airline terms
or flying terms, Where would you describe your current course
of your life flight right now?
S2 (42:26):
And I have to use the airline. Well, not.
S1 (42:28):
Specific. You don't have to, but just bonus points if
you get in a flying analogy.
S2 (42:33):
Yeah, well, I would say that I'm still up there
in the atmosphere flying around and still learning and still looking.
I'm not ready to land. I am flying around and
I'm enjoying it.
S1 (42:46):
Oh, God, that's so wonderful. And you're healthy. I mean,
we never really said that specifically, but in terms of
the cancer.
S2 (42:52):
I am now.
S1 (42:53):
Yeah, I'm.
S2 (42:54):
I'm 13 years out.
S1 (42:55):
And yes, that's wonderful.
S2 (42:57):
I take much better care of myself. My daughter was
right that I ate well. But I didn't know about
vitamin D. That was the only thing I think that
might have been a key. And I was I was
ignoring the stress, and I was hiding that from a
lot of people. Now, I don't take any drugs for
my stress. I don't need to because I have my bicycle.
S1 (43:21):
Oh, it's a perfect way.
S3 (43:22):
To end the cycles of your all those.
S1 (43:24):
Cycles of your life. Mean you've overcome hard things. I
want to say one more thing. I just thought I
think this is also such a lovely hour of testament
to your mom. I don't know if she's still alive
or not. You didn't say she is. What a guiding
force that you had in your mother. I mean, we're
trying to be a good mother, so we're here to
our younger kids. But just hearing you talk about watching
her go to work and I just I love that.
(43:45):
So thanks for sharing that on the family dinners. This
is really touching the image of that. Thank you. Dr. Kruger,
thank you so much for being with us, Sarah.
S2 (43:52):
Erica, Thank you. It was fun. Good. I enjoyed it.
S1 (43:55):
Thank you. Good. Thanks, Erica. And I want to say
thank you. We just completed our 21st podcast episode. Thank
you to all the listeners, all the shares and all
the feedback. We're toasting and celebrating 21 episodes and the
wrapping up of a series. Stay tuned for possible future
exciting changes. Please be advised that the information discussed on
this podcast is not professional therapy. If you are triggered
(44:19):
or activated, please don't be afraid to seek professional help and.
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