January 2, 2025 • 49 mins
Can drinking alcohol truly offer any health benefits, or is that just a myth we’re eager to believe? In this episode, we aim to inspire a renewed commitment to wellness in the new year with our guest, Dr. Ponni Perumalswami, a prominent hepatologist at the University of Michigan, who helps us unravel the complicated relationship between alcohol, the gut, and liver health. With her expertise, we tackle common misconceptions and explore the notion that less is more when it comes to alcohol consumption.
We dive into definitions that may surprise you, such as the different thresholds for binge drinking and heavy alcohol use among men and women. Dr. Perumalswami sheds light on the stigma associated with alcohol abuse and how it can impede access to support, urging healthcare professionals to improve patient assessments for alcohol use while providing a safe and supportive approach to care. We explore alcohol use disorder as a chronic brain condition and emphasize the essential need for comprehensive support for those affected. Additionally, we examine the interaction between alcohol use and common mental health conditions like anxiety and depression.
Whether you dabble in an occasional cocktail or perhaps have found yourself drinking more than you like, we provide tangible (and tasty) strategies for reducing alcohol intake and promoting healthier habits. Discover how simple changes such as opting for a fun mocktail and drinking less can enhance sleep, relationships, and overall well-being. Join us as we advocate for making informed choices towards a healthier, happier you.
References:
Alcohol's Impact on the Gut and Liver
Alcohol, the gut microbiome and liver disease
Check your alcohol intake with CDC's Quiz
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:20):
The Gut Health Podcast will empower you with a
fascinating scientificconnection between your brain,
food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:41):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Megan Riehl (00:45):
And I'm Dr Megan Riehl, a GI health
psychologist.
We have a very exciting podcastfor you today, because we are
talking about alcohol, the gutand going beyond that.
We are thrilled to be joined byDr.
Ponni Perumalswami, a leadinghepatologist and advocate for
liver health.
She is the director of theAlcohol Liver Disease Program at
(01:08):
the University of Michigan andthe director of the Liver Clinic
at the Ann Arbor VA.
Dr Ponni Perumalswami is arenowned clinician who manages
complex liver diseases, socertainly an expert for our
conversation today.
We are fortunate to have timewith her and we are going to
kick off this new year withsomething that a lot of people
(01:30):
are perhaps curious about andthat might be your liver
function.
So welcome, we are so thrilledto have you and we like to start
off our podcast with a mythbuster.
So what's a myth about alcoholor liver function that you'd
like to share with us today tokick off?
Ponni Perumalswami, MD (01:50):
That alcohol has health benefits.
I'll start by saying thank youfor having me.
I really appreciate you guysinviting me to join you guys for
this discussion today, but thatis the myth.
I would probably lead with.
Dr. Megan Riehl (02:01):
Wonderful.
So, with that in mind, thatspecific myth, let's start with
a question about is there a safeamount of alcohol that can be
consumed without causing harm tothe liver and the gut or any
potential amount of damage toour gut, health and beyond?
So let's talk about safety andalcohol.
Ponni Perumalswami, MD (02:23):
So this is a great question, I think.
Kick things off.
You know, our understanding ofalcohol has evolved a lot, I
would say, which I think hasactually made it incredibly
confusing for the general public.
I mean, we've always known thatalcohol is related and
associated with many differenttypes of harms, but what we now
know is that no alcohol is best.
(02:44):
Alcohol simply does not appearto convey any health benefits
whatsoever.
There used to be some beliefthat drinking certain types of
alcohol, for example, one glassof red wine a day, might lower
your risk of cardiovasculardisease, but that doesn't seem
to be the case with additionalstudies.
(03:04):
And I think, because of thiskind of confusion and knowing
that alcohol is associated withso many harms and we're seeing
even increases in these harmsover the last 10 years, in
December of 2022, the WorldHealth Organization published a
statement on this, and thestatement really was focused
that there's no safe amount ofalcohol to consume.
(03:26):
And then that was followed inthe heels in 2023 with the WHO,
the World Health Organization,declaring that the risk to
drinkers' health starts with thefirst drop of alcohol.
So when we're talking about,you know, safe, it's really hard
to really now knowing what wedo and having more kind of, I
think, public health messaging.
That's in line with what weknow, that alcohol is associated
(03:50):
with many different types ofrisks and known harms and, like,
one classic example of that is,for example, liver disease,
right, and we also know thatthere's been lots of
observations that some peoplewho drink alcohol versus those
who don't drink the same amountmight develop certain types of
problems, right, organdysfunction, for example.
(04:10):
So we know that toxicity ofalcohol is involved in
generating health complications,but it may be one of many
alcohol-induced changes andfactors that play a role in
developing some of the harms.
So if it's liver disease, ifit's changes in intestinal
microbiota, you know compositionor the function of that alcohol
(04:33):
plays a role.
Kate Scarlata (04:34):
I don't like organ dysfunction, like that's
probably not a good thing, right?
!
Ponni Perumalswami, MD (04:40):
Not a good thing to hear.
We don't want to ever betelling people that they're
having problems like healthproblems, particularly right,
related to alcohol.
Late people do have anassociation right like that.
Dr. Megan Riehl (04:51):
Some amount of drinking can cause liver
problems for example, what we'rehearing is that there really
aren't specific types ofalcoholic beverages that are
better or worse necessarily foryour overall gut health or liver
health.
Ponni Perumalswami, MD (05:12):
That's correct.
I mean, I often will say thebody, the liver specifically,
for example, it doesn't havetaste buds.
When it sees alcohol, it'sseeing alcohol and it's not
discriminating between whetheror not it's wine, it's beer, you
know hard liquor spirits.
So yeah, our body doesn't makeany distinguishing factors, if
(05:32):
you will, in seeing thedifferent types of alcohol.
Dr. Megan Riehl (05:35):
So you know we're not trying to be total
Debbie Downers here for the newyear and I think as you listen
to today's episode, if you enjoya glass of wine or two with
friends and family and thisenhances your social experiences
and brings joy without too manyoutward negative consequences,
(05:56):
then there probably is a waythat we can have a positive,
balanced relationship withalcohol.
Many people.
We're just going to encourageyou to stay mindful of the
reasons for your sip selectionsand the role that it plays in
your overall well-being.
Healthy relationships withalcohol is really our goal, and
for some people that's going toinclude moderation and tension
(06:19):
and the absence of a reliance onalcohol.
But for others, you may reallybe reflecting on how and when
and why you drink, which canempower the choices you make,
and for some that may mean thatalcohol isn't a part of your
life and your overall health andhappiness.
So just something to keep inmind as we talk about this with
(06:40):
our expert, who is reallyempowering us with information
today.
Kate Scarlata (06:45):
I couldn't agree more there, Megan, and I do
think that there are "somesocial benefits to engaging in
alcohol.
But I do think we all have tobe mindful and have sort of a
reality check with ourselves.
Is that one glass becoming twoglasses?
Is that two glass really half abottle, three quarters of the
(07:06):
bottle?
And being very mindful of theactual amounts that we're
consuming.
And having that reality check.
Women, you know no alcohol isgreat.
I think moderate is one glassper day.
That's seven glasses per week.
And what is a glass?
It's not these mondo glassesnine-ounce these pours that we
can get at some restaurants.
(07:28):
So just be mindful of quantities, how frequently, and be honest
with yourself, I think right.
So again, it doesn't have to benone.
But I think you also have tohave a talk with yourself about
how much you are actuallyconsuming.
I wanted to backpedal a littlebit because you did talk about
the microbiome and of course,being a gut health podcast, we
(07:51):
like to talk about that.
There are effects to the gutmicrobiome.
There are some effects to thetype of microbes that grow with
overconsumption of alcohol andeven some risk with small
intestinal bacterial overgrowth.
Can you just touch base alittle bit on SIBO and alcohol
consumption and educate ourlisteners on that topic a little
(08:14):
bit.
Ponni Perumalswami, MD (08:14):
Sure.
And you know, normally the gutmicrobiome has a healthy balance
of bacteria right.
The bacteria can be helpful inour bodies in many, many
different ways, includingsupporting our immune system,
supporting metabolisms orreactions that are happening or
need to happen in our body.
Regulating inflammation is animportant kind of part of what
(08:37):
gut microbiome is involved in,and it can also help defend
certain organs against toxins,particularly things like the
liver, and in that way the gutmicrobiome can be pretty
impactful, powerful, helpful inpreventing chronic and sometimes
infectious diseases.
So when we drink alcohol it canaffect everything from the
(09:00):
microbiome that we have in ourmouth all the way down into the
GI system, our digestive system,and it can involve lots of
organs along the ways.
And changes in the gutmicrobiota might be associated
with potentially causation andprogression of multiple
different types of problems inthe body, including one area,
(09:21):
for example, that's beingstudied a lot is with liver
disease, particularly withalcohol-related liver disease,
but even non-alcohol-relatedliver disease.
The gut microbiome isundergoing lots of study to see
how that impacts riskprogression outcomes with liver
disease.
So when we drink alcohol therecan be disruption of that gut
(09:43):
microbiome or changes in the gutmicrobiome, and there are
probably three main ways that wethink that the gut microbiome
might be impacted.
One is with the balance of goodversus bad kind of bacteria
that are kind of living togetherin harmony in our microbiome.
I'll just start by saying thatmost of the work with gut
(10:05):
microbiome and alcohol for manyyears has been done in animal
models, although there arestudies going back to the 1980s,
maybe even earlier, wherestarted to look at gut
microbiome in humans andsampling in different places and
trying to understand was theregut microbiome differences in
people who might have alcoholuse disorder, alcohol-associated
(10:28):
liver disease, and so therewere very early reported
differences right in like whatbacteria, how much, and what the
balance looked like.
So changes in the balance of thebacteria in the gut microbiome
are known as dysbiosis, whereyou get this disruption and kind
of what we think of as thishappy, calm medium into where
(10:50):
things are not balanced, thebest way to do all of the
important things that it needsto do.
So that's one way the gutbalance of bacteria can be
affected.
The other way is I justmentioned that gut microbiome is
really important formetabolizing things in our body
and reactions that need tohappen, so it might create the
(11:10):
different bacteria right as it'smetabolizing and involved in
the play of alcohol in thesystem, might create different
metabolites, and this can mightbe involved in signaling
pathways in both the liver, theblood, the intestinal kind of
pathway, and this can be alteredor break down when you have
(11:31):
alcohol as a toxin in the gut.
And then, finally, the last waythat people think, based on what
research has been done, is thatit might make the gut a little
bit more what we call leaky.
So we have protective mucuslayers in the gut that are kind
of kept in check by this nicebalance of bacteria in the
microbiome.
And when we drink alcohol andthat gets disrupted, then again
(11:56):
that protective layer betweenthe gut and the rest of our body
right, which then interactswith the blood system organs we
talk about gut-liver access,gut-brain access that gut
integrity can be broken down andcause the barrier protection,
if you will, and how itinterfaces then with blood and
all the other organs to bealtered.
(12:16):
So those would be the threemain ways that we know so far.
Kate Scarlata (12:21):
So interesting, and I think you know the gut and
you know the intestine and theliver are connected with a
particular what is it?
The enterohepatic circulation,what is that?
The portal vein, is that whatit is that connects the two?
So they're right there, they'reclose in proximity.
So if these metabolites arebeing made, it makes sense that
(12:42):
they can travel pretty readilyto the liver, right, correct?
Ponni Perumalswami, MD (12:46):
Yeah, and that's why you know there
are now like actually some humanstudies that are underway to
try to understand if there areways we can impact gut
microbiome in people who aredeveloping or have signs of, for
example, liver disease,alcohol-related liver disease,
particularly very advanced liverdisease.
There's been a couple ofrigorous what we call randomized
(13:09):
control trials trying to lookat if there's ways we can
administer prebiotics,probiotics, antibiotics or even
something called fecalmicrobiota transplant to see if
we can get a rebalance on gutmicrobiome and then thereby
impact positive outcomes, right.
So there's been, for example,some small studies looking at
(13:32):
patients with very severealcohol-associated hepatitis.
You know it's an acute form ofalcohol-related liver disease.
So people are studying if theygive them things like rifaximin,
right, or other probiotics oreven a fecal microbiotic
transplant, can this impactoutcomes positively?
So there's some early, smallerrandomized control data.
(13:53):
So it's like more rigorous kindof types of study that are
potentially pointing us in adirection of better
understanding how we might beable to use these methods to try
to improve outcomes, thingslike averting transplant,
improving survival, decreasinginflammation because you know
the pathway is also related tolots of stress, right, that
(14:14):
alcohol can kind of create invarious organs like the liver
and reducing that what we calloxidative stress.
Kate Scarlata (14:21):
Wow.
So I'm thinking about ourfriends with IBD and IBS, celiac
disease, they're already atrisk for this intestinal
permeability and altered gutmicrobiome.
So I would imagine might be alittle bit more cautious, if you
have those conditions, withyour alcohol consumption and I
(14:44):
always think about just theimpact of different types of
alcohol and mixers likeFODMAP-containing ones that's my
area of expertise and certainlyif you're downing a lot of
margaritas with agave syrupthat's a high FODMAP food that
could also sort of disrupt yoursymptoms and there's other
(15:05):
factors to consider here.
Ponni Perumalswami, MD (15:06):
Right, definitely so in people who
already have right, especiallyGI, intestinal issues, problems
right such as celiac disease,even irritable bowel syndrome,
to all the way more severeconditions like inflammatory
bowel disease, there's alreadydisruption and changes
potentially of gut microbiomehappening.
(15:28):
So think about alcohol beinganother potential mediator right
of either people potentiallydeveloping these problems in the
first place and or, if theyalready have it, then mediating
progression the same way we seelike, for example, in the liver.
I think there are very similarkind of circumstances there,
yeah, and impact.
Dr. Megan Riehl (15:47):
So people are looking for ways to improve
their overall health and theirlifestyle, and especially to
your point that if you alreadyare living with a GI condition
or really, quite honestly, anyhealth, physical health
condition or mental healthcondition, if we're looking for
a way to live a healthylifestyle, alcohol may be one of
(16:07):
those controllables that byabstaining or shifting to
another beverage in a beautifulcoop or cup or flute, that is a
mocktail or something that stillallows you the opportunity to
sit and be social and presentwith other people, but you know
(16:28):
that what you're choosing toingest is not going to cause you
worse than diarrhea the nextday or even a headache.
This is your opportunity tohave a little control when
oftentimes, with GI conditions,it can feel like the
unpredictability of yoursymptoms is really stressful.
So you're able to mediate oneof those stressors by maybe
(16:50):
putting something else in yourcup of choice.
Ponni Perumalswami, MD (16:53):
You know there's some definitions.
I think you started to kind ofspeak on this a little bit
earlier.
Is it helpful to review some oflike the definitions for what
we consider unhealthy alcoholuse?
I always find that that kind ofhelps ground, like, because I
think there's lots of confusionsabout like different terms we
often use, like what is bingedrinking, what is heavy alcohol
use?
Do you want me to review any ofthat?
(17:14):
Yeah, that would be great.
Okay, so just to add a touch ofconfusion, but not to get too
confused, you know we havedefinitions by different kind of
groups and so, just broadlyspeaking, you know binge
drinking is defined in womendifferently than men, right, in
women it's considered four ormore drinks, either within two
(17:37):
hours, one setting, or one day,depending on whose definition
you're looking at, and in men asfive or more in that same
timeframe.
Right, heavy alcohol use istypically defined as eight or
more drinks in women per weekand in men is 15 or more in the
same time frame.
And 90% of people who engage inbinge drinking episodes 90%, so
(18:02):
nine out of 10, will develop,for example, an early
manifestation of alcohol relatedliver disease.
So fatty liver, or what we callhepatic steatosis is the
medical term, and that willhappen within days to weeks.
But this is reversible as longas the drinking is not continued
in a heavy amount.
But if it does, then somewherebetween 10 and 35% of people
(18:24):
will go on to developinflammation plus fat and then
close to half of those patientsare at risk of developing what
we call scarring or fibrosis inthe liver and then over time, if
that continues, somewherebetween 8 and 20% are at risk
for developing significant, orwhat we call advanced, fibrosis
or cirrhosis.
So, as you just said, it'shelpful to know these thresholds
(18:48):
and what we consider bingedrinking or heavy alcohol use,
which we now also refer to asunhealthy alcohol use.
Right, because it raises evenmore associated harms or risks
from a health standpoint.
Kate Scarlata (18:59):
And I would just say I think a lot of people go
to their doctors and they sayyou know what's your alcohol use
?
It's, oh, social, you know.
And really as providers we needto dig a little deeper on that,
because one to two drinks mightnot sound terrible, but if it's
seven days a week for a woman,that's heavy alcohol use.
And I've only had one physicianthat really deep dived on that
(19:24):
with me was like no, like whatdo you mean social?
Tell me what that means.
I just think that we have,again, as physicians, providers,
we really need to deep dive alittle bit on what social
drinking means to thatindividual, because it sounds
kind of moderate but it mightnot really be in terms of the
(19:45):
terms you've just mentioned.
Ponni Perumalswami, MD (19:46):
Yeah, no , I think you're raising a
really really good point is thatwe do a not great job as
healthcare.
No, I think you're raising areally really good point is that
we do a not great job ashealthcare professionals, I
would say, unfortunately ofquantifying the amount of
alcohol.
And, as you just said, there'slike also what we consider one
standard drink, which is, in theUnited States, 14 grams of
alcohol in one drink.
You know, one drink might be atall pour, as you just said, or
(20:08):
a standard kind of size drink,depending on the type of alcohol
, right?
So we do a pour job of askingabout alcohol, getting it
quantifying and, unless wequantify it, using what we call
validated screening instruments.
And the best validatedscreening instrument is
(20:37):
something called the alcohol usedisorder identification test
and it comes in a mini form or ashort form which is three
questions and it gets at howmuch, how often and how much
binge drinking it is to exactlytry to understand who's at risk,
who's having an unhealthyamount of alcohol consumption.
(20:57):
So it's three questions.
Anybody can ask them.
If you actually have peopleself-administer it, they're more
likely to report an accurateamount, because alcohol use,
unfortunately, is very highlystigmatized, especially when
we're talking about it in thecontext of health.
People feel like they might getpenalized or have negative
consequences for not reportingaccurate amounts.
(21:21):
So using validated instrumentsis kind of how we can get at.
Oh, is somebody binge drinking?
Is somebody meeting adefinition for unhealthy alcohol
use?
And those three items add up toa score and if that score is
positive then patients should beactually evaluated for what we
call alcohol use disorder.
And that is the classic formatof doing that is through an
interview with a behavioralhealth provider.
(21:41):
And we have a definition foralcohol use disorder from the
Diagnostic Statistical Manual ofMental Health Disorders the
fifth edition and it has adefinition and it's defined also
with symptoms and there are upto 11 symptoms that are assessed
and if patients have two ormore of those symptoms they by
definition meet a diagnosis ofalcohol use disorder.
(22:02):
And people have now to try toget to more people being able to
diagnose alcohol use disorder.
They've actuallyoperationalized folks at RAND
have operationalized a checklistthat can be used in health
settings.
So some parts of, for example,like the Veterans Administration
, can have different types ofproviders, including sometimes
nurses, administer thatchecklist to try to get more
(22:22):
people involved in making adiagnosis.
So I think like think aboutscreening using validated
instruments in healthcaresettings.
I think like think aboutscreening using validated
instruments in healthcaresettings and then if you have
positive screening, then peopleneed to get evaluated a little
further for alcohol use disorder, because then we need to work
with patients to try to figureout how we can be helpful.
Dr. Megan Riehl (22:42):
Yeah, and if you've ever seen alcohol use
disorder on your own medicalrecord, I think even sometimes
that gets checked and it doesn'tnecessarily get discussed with
the patient, but based onscreening measures.
And so AUD, alcohol usedisorder it is.
It's a medical condition andit's characterized by impaired
(23:02):
ability to control your alcoholconsumption, despite the
negative consequences to health,relationships and your
day-to-day life.
And what's really important torecognize is that you are not
alone.
If this is something that youare struggling with, it's
chronic, it's a relapsing braindisorder.
I think that's what peoplereally, if your drinking has
(23:23):
progressed to the level ofdisorder, your brain is heavily
involved, and that's why workingwith a psychologist and good
medical providers oftentimes isthe necessity.
There was a 2021 study thatshowed that about 11% of
Americans meet criteria foralcohol use disorder, so that's
(23:46):
over one in 10.
And this is a very importantstatistic because it's not just
a medical condition.
It's one that impacts yourmental health as well, and we
see higher prevalence rates ofco-occurring depression and
anxiety often trauma as well, inpatients that are living with
AUD, and therefore it just makesthe importance of getting help
(24:10):
and resources and not going atthis alone that much more
imperative to really gettingyourself into a remission state
with your alcohol use.
So very important, very complexand certainly one that deserves
a team to support you with.
Ponni Perumalswami, MD (24:30):
Yeah, I would say the other thing, like
about destigmatizing it.
The more times we can thinkabout assessing for alcohol use,
I think is part of how we canget to destigmatizing it and
also capturing when there ispotentially unhealthy alcohol
use happening.
So we definitely charge primarycare, like the US Preventative
Services Task Force recommendsit to be done, like the
(24:51):
screening in all primary caresettings.
But as a field in GI,gastroenterology and hepatology,
we are now really talking abouthow it also needs to be done at
other points, and the morepoints that we do it where
patients are intersecting withcare, I think the more potential
we have to normalize and tode-stigmatize this discussion
(25:11):
and talking about alcohol withour patients and then also to
appropriately identify peopleright, because alcohol use can
change over time and it's veryintertwined, as you just said,
with other substances.
One out of eight people withalcohol use disorder have
co-occurring other substance usedisorders and we have seen an
increase in the number of peoplewho are living with alcohol use
disorder.
(25:31):
We estimate, based on like themost recent data, that close to
30 million people in the UnitedStates that are adults have a
diagnosis of alcohol usedisorder and it's, I would say,
severely undertreated.
Less than 10% of people here inthe United States, and then
globally, are engaged intreatment for alcohol use
disorder.
So lots of, I think,opportunities for identification
(25:52):
and then talking about how wecan leverage tools to help
people.
Kate Scarlata (25:57):
Yeah, I just think that it's.
You know you go to a socialevent and if you're not drinking
you're stigmatized.
You know, like there's so muchculture both ways.
Where you know, over-dr,addressing over drinking is
stigmatized, but on the otherside, if you go to a party,
there are people that arepressured to have a cocktail why
(26:20):
aren't you drinking, you know.
So there's a lot of culturalchange that needs to be done.
I'm seeing it with themillennials, I guess, right, or
is that the group Gen Z?
Which group is kind of beingmore non-alcohol?
They're probably doing more potbut less alcohol, right?
So we are seeing some shifts.
But I also think, in additionto screening, we all need to
(26:43):
know that alcohol content, evenin this, like craft beer
movement I love a good craftbeer, but some of them are 11%,
they're very high, and so, again, just educating our patients on
alcohol and content of things,yeah, it might be two beers, but
if they're 11% each and you'rehaving a 20-ounce pour, it's a
(27:03):
problem.
So there's lots of educationand change that needs to really
move forward for us to have ahealthy alcohol relationship, I
think.
Ponni Perumalswami, MD (27:15):
You definitely.
That is so spot on.
Like alcohol is a partparticularly in Western
countries, I would say, but evenglobally, it's just part of the
social fabric of how weinteract with other people,
particularly here in the UnitedStates, and so there is a lot of
work, though that is looking athow do we make some smart
policy decisions so that at apopulation level because these
(27:39):
things are being done in someother countries and have been
shown to decrease some of thebad outcomes we're seeing.
So you know, we've seen justthis enormous rise in people
with alcohol-related cirrhosis,for example, in the United
States it's overtaken all otherliver causes for cirrhosis and
death as a cause.
It's a leading cause for livertransplant, a rescue option when
(28:01):
we have patients with veryadvanced liver disease, and
these are not good things to beseeing, obviously, in our
populations.
These are not things anybodywants to see happening as a
consequence of alcohol.
So there are countries that areleading the way with some
policy decisions about how wecan make still allow for alcohol
but try to protect populationsfrom getting into trouble, and
(28:24):
we are a population where we'reseeing more and more harms,
unfortunately.
So I do think at some pointthinking about some broader
level changes and, as you said,like maybe even thinking about
how we better make peopleunderstand, like how much
alcohol is in your craft beerbefore you drink it.
So you understand what's thatthe equivalent of right?
(28:45):
Is that the equivalent of onedrink?
Is it equivalent of much morethan that or not?
Dr. Megan Riehl (28:52):
What if the secret to feeling happier and
healthier lies in your gut?
It's true, your gut producesabout 90% of your body's
serotonin, the feel-good hormone.
That means what you eat and howyou manage stress directly
impact not just your digestivehealth, but your mood too.
For the 11% of people globallyliving with irritable bowel
(29:14):
syndrome, this connection islife-changing.
Ibs can feel overwhelming, butthere's hope.
Introducing Mind Your Gut (29:21):
The Science-based, Whole- body Guide
to Living Well with IBS,co-authored by GI experts, Kate
Scarlata, a GI registereddietitian, and Dr.
Megan Riehl, a GI psychologist,this guide offers a holistic
and evidence-based approach toreclaiming your life, with
targeted mind-gut techniques,practical nutrition advice and
(29:45):
gut-soothing recipes.
It's your complete toolbox formanaging IBS and feeling your
best.
Don't let IBS control your life.
Take charge of your gut healthtoday with Mind Your Gut,
available now in hardcover andaudiobook formats wherever books
are sold.
Can you share with us a littlebit about how the liver
(30:06):
metabolizes alcohol and how thatcomes to affect things like
fatty liver and cirrhosis thatyou've mentioned and hepatitis
things like fatty liver andcirrhosis that you've mentioned,
and hepatitis.
Ponni Perumalswami, MD (30:21):
Yeah, so alcohol is metabolized by
several processes in the body,what we call like metabolic
processes or metabolism, and itmost commonly involves two
enzymes.
One is alcohol dehydrogenaseand the other enzyme is aldehyde
dehydrogenase.
And these enzymes help breakapart alcohol as a molecule to
make it possible for the body toeliminate it essentially.
(30:41):
Alcohol or ethanol, right asthe body sees it, broken down
first by the alcoholdehydrogenase or ADH enzyme and
that's found in the liver andthat takes ethanol right into a
toxic compound calledacetaldehyde.
And acetaldehyde is thenusually not hanging out in the
(31:03):
body very long and it's quicklybroken down further to a less
toxic compound called acetate.
And that's done by the secondenzyme I just mentioned, the
aldehyde dehydrogenase, and thenfrom there acetate gets broken
down to carbon dioxide and water, mainly in the tissues outside
of the liver.
So it undergoes like thisprocess to kind of break it down
(31:26):
so that the body can eliminateit.
But, as I just mentioned, youknow it's a binge drinking
episode right, or heavy alcoholuse in nine out of 10 patients,
for example in the liver, willgo on to still develop hepatic
steatosis.
But this is largely reversibleas long as like that amount
isn't kept up.
And when it is kept up, that'swhen we run into the problems
(31:46):
with alcohol-related liverdisease and then all the
downstream complications that wenever want to see.
The other thing I'll say is,like there, so like in the liver
, for example, like alcohol,it's a dose and duration
dependent major risk.
It's predominantly driven right.
Driving the alcohol, but thereare other factors, including
genetic factors, environmentalfactors, we know women, things
(32:10):
like history of bariatricsurgery.
There might be lots of othergenetic factors, some of which
are known, some of which are notwell known, and then lots of
other factors that are stillbeing studied that we may not
completely understand as beingrisk or putting people at risk
to develop bad outcomes fromlike alcohol-related liver
disease.
Kate Scarlata (32:28):
Keep thinking about those gut microbes.
They're somehow factored in,right?
Yeah, so some people getdiarrhea, some people feel
really bloated, some people getheartburn.
What is it about alcohol thatcreates these symptoms for some
people, and do you think it'sdose-related?
What's going on?
Ponni Perumalswami, MD (32:46):
Yeah, so the alcohol, like I just said,
obviously can cause lots ofdisruptions along the entire GI
tract and a lot of thosedisruptions can happen very high
up in the GI tract.
So breaking down, you know, thelining of the esophagus, for
example, can then manifest asheartburn, right, and if we
scope some patients who haveheavy alcohol use, we might
(33:06):
actually see something calledinflammation of the esophagus or
esophagitis.
We also see these changes canhappen in the stomach very
commonly, right, the first kindof places where alcohol is the
body seeing, if you will, theesophagus and the stomach, and
in the stomach it can do thesame thing with breaking down
the lining.
So, again, if we were to do anendoscopy, some patients might
(33:27):
actually have inflammation ofthe stomach or what we call
gastritis.
Some people might actuallydevelop ulcers, right ulcers,
and that can put you at risk forthings like bleeding.
And so these things, like whenpeople say like, oh, my tummy
hurts or my belly hurts after Idrink, it could be related to
some of these changes happeningand then, like as you just said,
some people might get bloating.
(33:48):
Bloating might be relatedsometimes to type of alcohol,
person's gut microbiome, howthey respond to things, and
other people may not ever havethese symptoms.
So it's like quite a range thatpeople can experience, but some
of these might be just likemanifestations of the physical
changes right that are happening, particularly in the esophagus
and the stomach, which is thefirst place the alcohol is kind
(34:09):
of hitting in our GI system.
Kate Scarlata (34:11):
Yeah, I think at the end of the day it's a GI
irritant system.
Yeah, I think at the end of theday, it's a GI irritant.
I think it can be reallyirritating to the gut and known
GI irritants.
Dr. Megan Riehl (34:22):
So that was a really beautiful way to explain
how it is one Well, and I'lltalk with patients too about
what are your behavioral choicesif you've been drinking and if
you've had a night of drinking.
And then you get home and thenext morning you wake up to the
pots and pans out because youfixed yourself some mac and
(34:44):
cheese and more snacks and maybesome ice cream and where you
stopped at McDonald's in yourUber or spent $40 at Taco Bell.
All of those choices on top ofthe alcohol consumption are
going to be a bit problematicfor you the next morning or,
unfortunately, for a lot ofpeople with GI conditions for
(35:05):
several days, even after a nightout.
Ponni Perumalswami, MD (35:10):
So that is exactly like that concept.
It sounds like a briefintervention.
So after we ask about alcohol,right, we find out about how
much, and then patients come tous obviously reporting lots of
symptoms in the context ofwhatever other things we might
be seeing them for or managingthem for.
So brief interventions they'rea behavioral treatment and it's
all about having just like thisfocused conversation about
(35:32):
alcohol and potentially relatedharms or how it's like, maybe
involved in symptoms that theymight be reporting and really
aimed at trying to then getpatients to be motivated to
create a change plan around thatalcohol behavior.
And this is actually veryeffective in people with
unhealthy alcohol use, so noteven having a diagnosis of
(35:52):
alcohol use disorder and theneven in patients with mild
alcohol use disorder or moderateto severe, to get them then
engaged if needed to movetowards treatment.
So, yes, this brief focusconversation of the impact of
alcohol is very powerful and atool we should be leveraging a
lot more when we see patients.
Dr. Megan Riehl (36:10):
Absolutely.
I talk about that in terms ofthis bidirectional relationship
with patients that have anxietyand depression, where I'll ask
about what are some of thethings going on in your life,
what are your coping skills tomanage your mood symptoms?
And for the patients that sayyou know well, I have a drink at
night and it really calms medown.
(36:30):
It calms the anxiety.
I don't feel those symptoms ofdepression as much anymore,
there's a technique calledmotivational interviewing, where
we start to gather informationfrom people and not to shame
them or stigmatize them aboutthe choices that they're
engaging in.
But education can go a long way.
(36:51):
So with depression specifically,I'll talk about the facts that
alcohol can intensify yourdepressive symptoms, maybe not
in the moment, but certainlybecause you're disrupting the
brain chemistry and for somepeople it's also impacting your
social relationships and thestability that you feel at work
or at school, and so further.
(37:12):
Problematic it becomes when thebrain chemistry, which the
neurotransmitter thatspecifically comes up is GABA,
which promotes relaxation, andthen serotonin, which affects
mood, is disrupted by alcoholuse, and so over time the brain
then becomes less capable ofmanaging whether it be anxiety
(37:35):
or depression, naturally, whichthen leads you to more drinking,
which becomes this very viciouscycle and so helping patients
to understand that their alcoholchoice in the short term is
going to create longer termproblems.
And so let's talk about how wecan create some healthier habits
(37:55):
that will actually get at theroot of why maybe you are
turning to numb or to calm, andsome strategies like relaxation,
exercise, healthy socialconnection, making sure that
you've got a good medical team,making sure that you're open and
honest.
A lot of people that aredrinking alcohol are probably
(38:17):
living with shame or guilt iftheir alcohol relationship is
unhealthy.
So again, that's not togeneralize to all people
drinking alcohol, but if you'resomebody who wakes up the next
day and kind of feels some ofthat emotional sensation of oh,
what did I say last night, ordid I do something?
(38:37):
Or maybe you know I got behindthe wheel of a car and I
probably shouldn't have donethat last night, if you're
having any of those questioningthoughts, just make sure that
you start to talk about thatwith somebody and know that
there are available resources tohelp you.
Kate Scarlata (38:53):
Yeah, and I would say too, you know I've
worked with some clients thatcome in and say, geez, you know
I feel really bad on Monday,like the beginning of the week,
and come to find out they'reweekend warriors, you know.
So they're partying hard on theweekends and it really has
downstream effects to their gutand so we start seeing these
patterns and then you helpidentify the patterns to their
(39:16):
GI symptoms and they're morelikely to go oh aha, you're
right.
I probably need to really focuson that if I don't want to have
major diarrhea on Mondays.
Connect the dots as providersand certainly our listeners.
(39:39):
Hopefully you can also connectsome dots with your own personal
story and the way you're usingalcohol or not using alcohol.
What do you say to yourpatients about just ways to
mitigate specific goals for them?
What are some of the goals thatyou suggest to help them
decrease their alcohol?
There are certain techniquesthat you use in practice.
Ponni Perumalswami, MD (40:00):
So one is just like having a very open,
honest conversation, like aplace like where patients can
feel reassured that what they'regoing to get from me is lots of
empathy and like lots oflistening and then also help if
they're wanting it.
But it's also helpful for themto know, like how we can be
helpful, and I think a lot ofpeople don't understand or know
(40:22):
all the different ways maybe wemight be able to be helpful.
So obviously I see lots ofpatients who have an alcohol use
disorder in the context ofliver disease and so I always
make sure patients are veryaware of different types of
treatment we have for patients.
Making sure they know thatthere's both medications as well
(40:44):
as behavioral treatments youwere just mentioning.
You know cognitive behavioraltherapy, for example, is a type
of more intense, focused,skill-based therapy right.
To get patients to try to copeand change how they're using
alcohol to cope with problemsthat often kind of coexist or
co-occur and just occur reallycommonly for everybody in their
(41:05):
everyday lives If it's stress,it's anxiety, it's depression in
the context of having a boweldisorder or a liver disease.
So making sure they know thereare lots of tools we have in our
toolbox.
I find that, like a lot ofpatients might have a slice of
the understanding of what wehave to offer, even with
medications.
You know, the one medication Ifind, for example, everybody has
(41:26):
awareness about is likeAntabuse or disulfiram.
It's the one medication wenever give patients with liver
disease because of livertoxicity and so like then
talking about all the differentother medications we have, if
they're interested and howmedication and or behavioral
therapies can be helpful forsomebody who, in the context
we're talking about thesenegative maybe health
(41:47):
consequences or harms thatthey're experiencing, how these
treatments can be helpful and ifthey're not able to do it on
their own right, like that'swhere Medicaid but they want to
and really making patients feellike super centered in these
discussions is, I think, veryimportant, so that this is all
about how we can be helpful toyou and what do you want, how do
(42:07):
you want us to help you, andthen again asking about it, not
just once, but asking about itand offering treatment early
often and keeping patientsengaged around this discussion,
because they may not want itmaybe at the start of like wait
when you have this firstconversation, but after they're
(42:27):
building a relationship with youor they're seeing maybe other
negative health consequenceshappening.
You might just find the rightkind of window where patient's
motivation has changed, and Ialso really try to medicalize
this in a way.
I also let patients know 50% ofalcohol use disorder is
hereditary.
So in the same way that somepatients are diabetic but not
(42:49):
overweight or have high bloodpressure and are taking, you
know, need medications, oneperson might need medications.
Another person may not needmedications, might be able to do
with some diet and exercise.
That we want to have the sameapproach, that you know we have
treatments to offer.
And how do you want us to behelpful?
Kate Scarlata (43:08):
I love that.
I think too, like just this isyou know you're dealing with
people that are in it and have adisorder, and then there's the
other spectrum of people justmaybe dabbling a little bit too
much and you know, for thatcrowd I really try to get them
to think about have a seltzer,then have a glass of wine, or
(43:30):
have a spritzer instead of theglass of wine, or think about
some of the non-alcoholic beersthat are out there that are
tasty.
If you want to participate inyou know last call, but you
really don't want to have analcoholic beverage, consider a
non-alcoholic option.
There's so many cool mocktails,as Dr Riehl mentioned earlier,
(43:52):
that can feel festive and thatyou're part of the crowd.
Having seltzer with a littlesplash of cranberry and a lime
looks like a cocktail and youdon't have to deal with the
commentary.
So there are little strategiesfor those that are on the well I
really want to cut down, but Idon't have a liver disorder, but
I don't want to get one andaddressing those patients which
(44:15):
I see frequently they just needto dial it back and need some
tools to do so.
Ponni Perumalswami, MD (44:20):
Yeah, yeah.
So I think, yeah, we need toaddress people much earlier,
right before they develop.
And, yeah, making sure peopleknow that they have these other
options to have non-alcoholicchoices and to still feel like
they fit in in social settings,because that is a big part of
how alcohol is consumed.
It's really part of the socialfabric in a lot of different
(44:42):
cultures.
I also think, like highlightingwhat patients tell us right
after they cut back or they stop, even in those settings, that
they tend to sleep better, theytend to feel better, they tend
to have better personalrelationships.
So making sure we'rehighlighting all of the
potential positive things thatcan come right with making some
small changes, like, as you said, this summer I started kind of
(45:05):
exploring mocktails and myfavorite seems to be
transitioning well from summerto winter.
Dr. Megan Riehl (45:13):
I love a little ginger beer with a squeeze of
lime and then I just add to it.
So whatever else I want, if Iwant it a little spicy, I'll do
a slice of jalapeno.
If I want it more festive, Ican throw in some rosemary.
So maybe our listeners canshare their favorite mocktail
recipes with us too.
And I also then feel reallycomfortable with my kids seeing
(45:38):
me make this.
So they're observing, mom,that's putting something
together to drink.
That's not just water or coffeeor tea, but if they have a sip
of it, whereas if you have aglass of wine or something and
inevitably your child comes overand they pick it up and it's
like no, no, no, no, that's formommy, that's mommy's drink.
It's like if they want to try asip of it, sure you can have a
(45:59):
sip of this.
So certainly our relationshipswith alcohol are individualized
and personal, and if you needsomebody to talk to about it, I
encourage you to do that.
Hepatologists like DrPerumalswami are like you know.
You're right.
The empathy just exudes out ofyou and you create a safe space
(46:21):
for people that really allowthem to embrace their health
journey, and that's really whateverybody certainly deserves.
So with that, I just want tothank you so much for your
expertise.
Today we're all kind of lookingat this brand new year and
maybe rethinking relationships,whether it be with alcohol or
(46:43):
broader health and wellnessgoals, and we are here.
The Gut Health Podcast, Kateand I are going to be with you
all year long talking about ourgut health and really hoping to
inspire everyone along the way.
As we wrap up at this episode,we like to ask all of our guests
the following questions.
So, for the first time in 2025,Dr.
Perumalswami, what is somethingthat you prioritize when it
(47:09):
comes to your own health andwellness?
Ponni Perumalswami, MD (47:12):
I'm hoping to like be working out
more.
I would say, you know I'malways like challenged with
trying to figure out, you know,the balance.
I think I hear this a lot frompatients.
I'm also, you know, we're allpatients also too right In some
capacity, and so like I feellike eating healthier and being
more active is something I'malways trying to, particularly
(47:33):
not just in the new year butthroughout the year.
But recommitting in the newyear to trying to do so.
I just signed up for a workoutclass at our community center.
They're continuing it.
Yeah, so that's my commitmentfor the new year.
Dr. Megan Riehl (47:45):
You deserve it, good.
Kate Scarlata (47:47):
It's perfect.
It's so perfect.
Well, thank you so much forcoming on today.
Really informative.
I love your patient-centeredcare model.
Really today, reallyinformative.
I love your patient-centeredcare model.
Really important to The thepatient be the center of their
universe and their healthcare.
So thanks for all the work thatyou do and sharing your level
of expertise with our listenerstoday as we kick off our 2025
(48:09):
season.
So please make sure yousubscribe, follow and like The
Gut Health Podcast.
Your support means the worldfriends.
Dr. Megan Riehl (48:19):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at The Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
The Gut Health Podcast will empower you with a
fascinating scientificconnection between your brain,
food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:41):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Megan Riehl (00:45):
And I'm Dr Megan Riehl, a GI health
psychologist.
We have a very exciting podcastfor you today, because we are
talking about alcohol, the gutand going beyond that.
We are thrilled to be joined byDr.
Ponni Perumalswami, a leadinghepatologist and advocate for
liver health.
She is the director of theAlcohol Liver Disease Program at
(01:08):
the University of Michigan andthe director of the Liver Clinic
at the Ann Arbor VA.
Dr Ponni Perumalswami is arenowned clinician who manages
complex liver diseases, socertainly an expert for our
conversation today.
We are fortunate to have timewith her and we are going to
kick off this new year withsomething that a lot of people
(01:30):
are perhaps curious about andthat might be your liver
function.
So welcome, we are so thrilledto have you and we like to start
off our podcast with a mythbuster.
So what's a myth about alcoholor liver function that you'd
like to share with us today tokick off?
Ponni Perumalswami, MD (01:50):
That alcohol has health benefits.
I'll start by saying thank youfor having me.
I really appreciate you guysinviting me to join you guys for
this discussion today, but thatis the myth.
I would probably lead with.
Dr. Megan Riehl (02:01):
Wonderful.
So, with that in mind, thatspecific myth, let's start with
a question about is there a safeamount of alcohol that can be
consumed without causing harm tothe liver and the gut or any
potential amount of damage toour gut, health and beyond?
So let's talk about safety andalcohol.
Ponni Perumalswami, MD (02:23):
So this is a great question, I think.
Kick things off.
You know, our understanding ofalcohol has evolved a lot, I
would say, which I think hasactually made it incredibly
confusing for the general public.
I mean, we've always known thatalcohol is related and
associated with many differenttypes of harms, but what we now
know is that no alcohol is best.
(02:44):
Alcohol simply does not appearto convey any health benefits
whatsoever.
There used to be some beliefthat drinking certain types of
alcohol, for example, one glassof red wine a day, might lower
your risk of cardiovasculardisease, but that doesn't seem
to be the case with additionalstudies.
(03:04):
And I think, because of thiskind of confusion and knowing
that alcohol is associated withso many harms and we're seeing
even increases in these harmsover the last 10 years, in
December of 2022, the WorldHealth Organization published a
statement on this, and thestatement really was focused
that there's no safe amount ofalcohol to consume.
(03:26):
And then that was followed inthe heels in 2023 with the WHO,
the World Health Organization,declaring that the risk to
drinkers' health starts with thefirst drop of alcohol.
So when we're talking about,you know, safe, it's really hard
to really now knowing what wedo and having more kind of, I
think, public health messaging.
That's in line with what weknow, that alcohol is associated
(03:50):
with many different types ofrisks and known harms and, like,
one classic example of that is,for example, liver disease,
right, and we also know thatthere's been lots of
observations that some peoplewho drink alcohol versus those
who don't drink the same amountmight develop certain types of
problems, right, organdysfunction, for example.
(04:10):
So we know that toxicity ofalcohol is involved in
generating health complications,but it may be one of many
alcohol-induced changes andfactors that play a role in
developing some of the harms.
So if it's liver disease, ifit's changes in intestinal
microbiota, you know compositionor the function of that alcohol
(04:33):
plays a role.
Kate Scarlata (04:34):
I don't like organ dysfunction, like that's
probably not a good thing, right?
!
Ponni Perumalswami, MD (04:40):
Not a good thing to hear.
We don't want to ever betelling people that they're
having problems like healthproblems, particularly right,
related to alcohol.
Late people do have anassociation right like that.
Dr. Megan Riehl (04:51):
Some amount of drinking can cause liver
problems for example, what we'rehearing is that there really
aren't specific types ofalcoholic beverages that are
better or worse necessarily foryour overall gut health or liver
health.
Ponni Perumalswami, MD (05:12):
That's correct.
I mean, I often will say thebody, the liver specifically,
for example, it doesn't havetaste buds.
When it sees alcohol, it'sseeing alcohol and it's not
discriminating between whetheror not it's wine, it's beer, you
know hard liquor spirits.
So yeah, our body doesn't makeany distinguishing factors, if
(05:32):
you will, in seeing thedifferent types of alcohol.
Dr. Megan Riehl (05:35):
So you know we're not trying to be total
Debbie Downers here for the newyear and I think as you listen
to today's episode, if you enjoya glass of wine or two with
friends and family and thisenhances your social experiences
and brings joy without too manyoutward negative consequences,
(05:56):
then there probably is a waythat we can have a positive,
balanced relationship withalcohol.
Many people.
We're just going to encourageyou to stay mindful of the
reasons for your sip selectionsand the role that it plays in
your overall well-being.
Healthy relationships withalcohol is really our goal, and
for some people that's going toinclude moderation and tension
(06:19):
and the absence of a reliance onalcohol.
But for others, you may reallybe reflecting on how and when
and why you drink, which canempower the choices you make,
and for some that may mean thatalcohol isn't a part of your
life and your overall health andhappiness.
So just something to keep inmind as we talk about this with
(06:40):
our expert, who is reallyempowering us with information
today.
Kate Scarlata (06:45):
I couldn't agree more there, Megan, and I do
think that there are "somesocial benefits to engaging in
alcohol.
But I do think we all have tobe mindful and have sort of a
reality check with ourselves.
Is that one glass becoming twoglasses?
Is that two glass really half abottle, three quarters of the
(07:06):
bottle?
And being very mindful of theactual amounts that we're
consuming.
And having that reality check.
Women, you know no alcohol isgreat.
I think moderate is one glassper day.
That's seven glasses per week.
And what is a glass?
It's not these mondo glassesnine-ounce these pours that we
can get at some restaurants.
(07:28):
So just be mindful of quantities, how frequently, and be honest
with yourself, I think right.
So again, it doesn't have to benone.
But I think you also have tohave a talk with yourself about
how much you are actuallyconsuming.
I wanted to backpedal a littlebit because you did talk about
the microbiome and of course,being a gut health podcast, we
(07:51):
like to talk about that.
There are effects to the gutmicrobiome.
There are some effects to thetype of microbes that grow with
overconsumption of alcohol andeven some risk with small
intestinal bacterial overgrowth.
Can you just touch base alittle bit on SIBO and alcohol
consumption and educate ourlisteners on that topic a little
(08:14):
bit.
Ponni Perumalswami, MD (08:14):
Sure.
And you know, normally the gutmicrobiome has a healthy balance
of bacteria right.
The bacteria can be helpful inour bodies in many, many
different ways, includingsupporting our immune system,
supporting metabolisms orreactions that are happening or
need to happen in our body.
Regulating inflammation is animportant kind of part of what
(08:37):
gut microbiome is involved in,and it can also help defend
certain organs against toxins,particularly things like the
liver, and in that way the gutmicrobiome can be pretty
impactful, powerful, helpful inpreventing chronic and sometimes
infectious diseases.
So when we drink alcohol it canaffect everything from the
(09:00):
microbiome that we have in ourmouth all the way down into the
GI system, our digestive system,and it can involve lots of
organs along the ways.
And changes in the gutmicrobiota might be associated
with potentially causation andprogression of multiple
different types of problems inthe body, including one area,
(09:21):
for example, that's beingstudied a lot is with liver
disease, particularly withalcohol-related liver disease,
but even non-alcohol-relatedliver disease.
The gut microbiome isundergoing lots of study to see
how that impacts riskprogression outcomes with liver
disease.
So when we drink alcohol therecan be disruption of that gut
(09:43):
microbiome or changes in the gutmicrobiome, and there are
probably three main ways that wethink that the gut microbiome
might be impacted.
One is with the balance of goodversus bad kind of bacteria
that are kind of living togetherin harmony in our microbiome.
I'll just start by saying thatmost of the work with gut
(10:05):
microbiome and alcohol for manyyears has been done in animal
models, although there arestudies going back to the 1980s,
maybe even earlier, wherestarted to look at gut
microbiome in humans andsampling in different places and
trying to understand was theregut microbiome differences in
people who might have alcoholuse disorder, alcohol-associated
(10:28):
liver disease, and so therewere very early reported
differences right in like whatbacteria, how much, and what the
balance looked like.
So changes in the balance of thebacteria in the gut microbiome
are known as dysbiosis, whereyou get this disruption and kind
of what we think of as thishappy, calm medium into where
(10:50):
things are not balanced, thebest way to do all of the
important things that it needsto do.
So that's one way the gutbalance of bacteria can be
affected.
The other way is I justmentioned that gut microbiome is
really important formetabolizing things in our body
and reactions that need tohappen, so it might create the
(11:10):
different bacteria right as it'smetabolizing and involved in
the play of alcohol in thesystem, might create different
metabolites, and this can mightbe involved in signaling
pathways in both the liver, theblood, the intestinal kind of
pathway, and this can be alteredor break down when you have
(11:31):
alcohol as a toxin in the gut.
And then, finally, the last waythat people think, based on what
research has been done, is thatit might make the gut a little
bit more what we call leaky.
So we have protective mucuslayers in the gut that are kind
of kept in check by this nicebalance of bacteria in the
microbiome.
And when we drink alcohol andthat gets disrupted, then again
(11:56):
that protective layer betweenthe gut and the rest of our body
right, which then interactswith the blood system organs we
talk about gut-liver access,gut-brain access that gut
integrity can be broken down andcause the barrier protection,
if you will, and how itinterfaces then with blood and
all the other organs to bealtered.
(12:16):
So those would be the threemain ways that we know so far.
Kate Scarlata (12:21):
So interesting, and I think you know the gut and
you know the intestine and theliver are connected with a
particular what is it?
The enterohepatic circulation,what is that?
The portal vein, is that whatit is that connects the two?
So they're right there, they'reclose in proximity.
So if these metabolites arebeing made, it makes sense that
(12:42):
they can travel pretty readilyto the liver, right, correct?
Ponni Perumalswami, MD (12:46):
Yeah, and that's why you know there
are now like actually some humanstudies that are underway to
try to understand if there areways we can impact gut
microbiome in people who aredeveloping or have signs of, for
example, liver disease,alcohol-related liver disease,
particularly very advanced liverdisease.
There's been a couple ofrigorous what we call randomized
(13:09):
control trials trying to lookat if there's ways we can
administer prebiotics,probiotics, antibiotics or even
something called fecalmicrobiota transplant to see if
we can get a rebalance on gutmicrobiome and then thereby
impact positive outcomes, right.
So there's been, for example,some small studies looking at
(13:32):
patients with very severealcohol-associated hepatitis.
You know it's an acute form ofalcohol-related liver disease.
So people are studying if theygive them things like rifaximin,
right, or other probiotics oreven a fecal microbiotic
transplant, can this impactoutcomes positively?
So there's some early, smallerrandomized control data.
(13:53):
So it's like more rigorous kindof types of study that are
potentially pointing us in adirection of better
understanding how we might beable to use these methods to try
to improve outcomes, thingslike averting transplant,
improving survival, decreasinginflammation because you know
the pathway is also related tolots of stress, right, that
(14:14):
alcohol can kind of create invarious organs like the liver
and reducing that what we calloxidative stress.
Kate Scarlata (14:21):
Wow.
So I'm thinking about ourfriends with IBD and IBS, celiac
disease, they're already atrisk for this intestinal
permeability and altered gutmicrobiome.
So I would imagine might be alittle bit more cautious, if you
have those conditions, withyour alcohol consumption and I
(14:44):
always think about just theimpact of different types of
alcohol and mixers likeFODMAP-containing ones that's my
area of expertise and certainlyif you're downing a lot of
margaritas with agave syrupthat's a high FODMAP food that
could also sort of disrupt yoursymptoms and there's other
(15:05):
factors to consider here.
Ponni Perumalswami, MD (15:06):
Right, definitely so in people who
already have right, especiallyGI, intestinal issues, problems
right such as celiac disease,even irritable bowel syndrome,
to all the way more severeconditions like inflammatory
bowel disease, there's alreadydisruption and changes
potentially of gut microbiomehappening.
(15:28):
So think about alcohol beinganother potential mediator right
of either people potentiallydeveloping these problems in the
first place and or, if theyalready have it, then mediating
progression the same way we seelike, for example, in the liver.
I think there are very similarkind of circumstances there,
yeah, and impact.
Dr. Megan Riehl (15:47):
So people are looking for ways to improve
their overall health and theirlifestyle, and especially to
your point that if you alreadyare living with a GI condition
or really, quite honestly, anyhealth, physical health
condition or mental healthcondition, if we're looking for
a way to live a healthylifestyle, alcohol may be one of
(16:07):
those controllables that byabstaining or shifting to
another beverage in a beautifulcoop or cup or flute, that is a
mocktail or something that stillallows you the opportunity to
sit and be social and presentwith other people, but you know
(16:28):
that what you're choosing toingest is not going to cause you
worse than diarrhea the nextday or even a headache.
This is your opportunity tohave a little control when
oftentimes, with GI conditions,it can feel like the
unpredictability of yoursymptoms is really stressful.
So you're able to mediate oneof those stressors by maybe
(16:50):
putting something else in yourcup of choice.
Ponni Perumalswami, MD (16:53):
You know there's some definitions.
I think you started to kind ofspeak on this a little bit
earlier.
Is it helpful to review some oflike the definitions for what
we consider unhealthy alcoholuse?
I always find that that kind ofhelps ground, like, because I
think there's lots of confusionsabout like different terms we
often use, like what is bingedrinking, what is heavy alcohol
use?
Do you want me to review any ofthat?
(17:14):
Yeah, that would be great.
Okay, so just to add a touch ofconfusion, but not to get too
confused, you know we havedefinitions by different kind of
groups and so, just broadlyspeaking, you know binge
drinking is defined in womendifferently than men, right, in
women it's considered four ormore drinks, either within two
(17:37):
hours, one setting, or one day,depending on whose definition
you're looking at, and in men asfive or more in that same
timeframe.
Right, heavy alcohol use istypically defined as eight or
more drinks in women per weekand in men is 15 or more in the
same time frame.
And 90% of people who engage inbinge drinking episodes 90%, so
(18:02):
nine out of 10, will develop,for example, an early
manifestation of alcohol relatedliver disease.
So fatty liver, or what we callhepatic steatosis is the
medical term, and that willhappen within days to weeks.
But this is reversible as longas the drinking is not continued
in a heavy amount.
But if it does, then somewherebetween 10 and 35% of people
(18:24):
will go on to developinflammation plus fat and then
close to half of those patientsare at risk of developing what
we call scarring or fibrosis inthe liver and then over time, if
that continues, somewherebetween 8 and 20% are at risk
for developing significant, orwhat we call advanced, fibrosis
or cirrhosis.
So, as you just said, it'shelpful to know these thresholds
(18:48):
and what we consider bingedrinking or heavy alcohol use,
which we now also refer to asunhealthy alcohol use.
Right, because it raises evenmore associated harms or risks
from a health standpoint.
Kate Scarlata (18:59):
And I would just say I think a lot of people go
to their doctors and they sayyou know what's your alcohol use
?
It's, oh, social, you know.
And really as providers we needto dig a little deeper on that,
because one to two drinks mightnot sound terrible, but if it's
seven days a week for a woman,that's heavy alcohol use.
And I've only had one physicianthat really deep dived on that
(19:24):
with me was like no, like whatdo you mean social?
Tell me what that means.
I just think that we have,again, as physicians, providers,
we really need to deep dive alittle bit on what social
drinking means to thatindividual, because it sounds
kind of moderate but it mightnot really be in terms of the
(19:45):
terms you've just mentioned.
Ponni Perumalswami, MD (19:46):
Yeah, no , I think you're raising a
really really good point is thatwe do a not great job as
healthcare.
No, I think you're raising areally really good point is that
we do a not great job ashealthcare professionals, I
would say, unfortunately ofquantifying the amount of
alcohol.
And, as you just said, there'slike also what we consider one
standard drink, which is, in theUnited States, 14 grams of
alcohol in one drink.
You know, one drink might be atall pour, as you just said, or
(20:08):
a standard kind of size drink,depending on the type of alcohol
, right?
So we do a pour job of askingabout alcohol, getting it
quantifying and, unless wequantify it, using what we call
validated screening instruments.
And the best validatedscreening instrument is
(20:37):
something called the alcohol usedisorder identification test
and it comes in a mini form or ashort form which is three
questions and it gets at howmuch, how often and how much
binge drinking it is to exactlytry to understand who's at risk,
who's having an unhealthyamount of alcohol consumption.
(20:57):
So it's three questions.
Anybody can ask them.
If you actually have peopleself-administer it, they're more
likely to report an accurateamount, because alcohol use,
unfortunately, is very highlystigmatized, especially when
we're talking about it in thecontext of health.
People feel like they might getpenalized or have negative
consequences for not reportingaccurate amounts.
(21:21):
So using validated instrumentsis kind of how we can get at.
Oh, is somebody binge drinking?
Is somebody meeting adefinition for unhealthy alcohol
use?
And those three items add up toa score and if that score is
positive then patients should beactually evaluated for what we
call alcohol use disorder.
And that is the classic formatof doing that is through an
interview with a behavioralhealth provider.
(21:41):
And we have a definition foralcohol use disorder from the
Diagnostic Statistical Manual ofMental Health Disorders the
fifth edition and it has adefinition and it's defined also
with symptoms and there are upto 11 symptoms that are assessed
and if patients have two ormore of those symptoms they by
definition meet a diagnosis ofalcohol use disorder.
(22:02):
And people have now to try toget to more people being able to
diagnose alcohol use disorder.
They've actuallyoperationalized folks at RAND
have operationalized a checklistthat can be used in health
settings.
So some parts of, for example,like the Veterans Administration
, can have different types ofproviders, including sometimes
nurses, administer thatchecklist to try to get more
(22:22):
people involved in making adiagnosis.
So I think like think aboutscreening using validated
instruments in healthcaresettings.
I think like think aboutscreening using validated
instruments in healthcaresettings and then if you have
positive screening, then peopleneed to get evaluated a little
further for alcohol use disorder, because then we need to work
with patients to try to figureout how we can be helpful.
Dr. Megan Riehl (22:42):
Yeah, and if you've ever seen alcohol use
disorder on your own medicalrecord, I think even sometimes
that gets checked and it doesn'tnecessarily get discussed with
the patient, but based onscreening measures.
And so AUD, alcohol usedisorder it is.
It's a medical condition andit's characterized by impaired
(23:02):
ability to control your alcoholconsumption, despite the
negative consequences to health,relationships and your
day-to-day life.
And what's really important torecognize is that you are not
alone.
If this is something that youare struggling with, it's
chronic, it's a relapsing braindisorder.
I think that's what peoplereally, if your drinking has
(23:23):
progressed to the level ofdisorder, your brain is heavily
involved, and that's why workingwith a psychologist and good
medical providers oftentimes isthe necessity.
There was a 2021 study thatshowed that about 11% of
Americans meet criteria foralcohol use disorder, so that's
(23:46):
over one in 10.
And this is a very importantstatistic because it's not just
a medical condition.
It's one that impacts yourmental health as well, and we
see higher prevalence rates ofco-occurring depression and
anxiety often trauma as well, inpatients that are living with
AUD, and therefore it just makesthe importance of getting help
(24:10):
and resources and not going atthis alone that much more
imperative to really gettingyourself into a remission state
with your alcohol use.
So very important, very complexand certainly one that deserves
a team to support you with.
Ponni Perumalswami, MD (24:30):
Yeah, I would say the other thing, like
about destigmatizing it.
The more times we can thinkabout assessing for alcohol use,
I think is part of how we canget to destigmatizing it and
also capturing when there ispotentially unhealthy alcohol
use happening.
So we definitely charge primarycare, like the US Preventative
Services Task Force recommendsit to be done, like the
(24:51):
screening in all primary caresettings.
But as a field in GI,gastroenterology and hepatology,
we are now really talking abouthow it also needs to be done at
other points, and the morepoints that we do it where
patients are intersecting withcare, I think the more potential
we have to normalize and tode-stigmatize this discussion
(25:11):
and talking about alcohol withour patients and then also to
appropriately identify peopleright, because alcohol use can
change over time and it's veryintertwined, as you just said,
with other substances.
One out of eight people withalcohol use disorder have
co-occurring other substance usedisorders and we have seen an
increase in the number of peoplewho are living with alcohol use
disorder.
(25:31):
We estimate, based on like themost recent data, that close to
30 million people in the UnitedStates that are adults have a
diagnosis of alcohol usedisorder and it's, I would say,
severely undertreated.
Less than 10% of people here inthe United States, and then
globally, are engaged intreatment for alcohol use
disorder.
So lots of, I think,opportunities for identification
(25:52):
and then talking about how wecan leverage tools to help
people.
Kate Scarlata (25:57):
Yeah, I just think that it's.
You know you go to a socialevent and if you're not drinking
you're stigmatized.
You know, like there's so muchculture both ways.
Where you know, over-dr,addressing over drinking is
stigmatized, but on the otherside, if you go to a party,
there are people that arepressured to have a cocktail why
(26:20):
aren't you drinking, you know.
So there's a lot of culturalchange that needs to be done.
I'm seeing it with themillennials, I guess, right, or
is that the group Gen Z?
Which group is kind of beingmore non-alcohol?
They're probably doing more potbut less alcohol, right?
So we are seeing some shifts.
But I also think, in additionto screening, we all need to
(26:43):
know that alcohol content, evenin this, like craft beer
movement I love a good craftbeer, but some of them are 11%,
they're very high, and so, again, just educating our patients on
alcohol and content of things,yeah, it might be two beers, but
if they're 11% each and you'rehaving a 20-ounce pour, it's a
(27:03):
problem.
So there's lots of educationand change that needs to really
move forward for us to have ahealthy alcohol relationship, I
think.
Ponni Perumalswami, MD (27:15):
You definitely.
That is so spot on.
Like alcohol is a partparticularly in Western
countries, I would say, but evenglobally, it's just part of the
social fabric of how weinteract with other people,
particularly here in the UnitedStates, and so there is a lot of
work, though that is looking athow do we make some smart
policy decisions so that at apopulation level because these
(27:39):
things are being done in someother countries and have been
shown to decrease some of thebad outcomes we're seeing.
So you know, we've seen justthis enormous rise in people
with alcohol-related cirrhosis,for example, in the United
States it's overtaken all otherliver causes for cirrhosis and
death as a cause.
It's a leading cause for livertransplant, a rescue option when
(28:01):
we have patients with veryadvanced liver disease, and
these are not good things to beseeing, obviously, in our
populations.
These are not things anybodywants to see happening as a
consequence of alcohol.
So there are countries that areleading the way with some
policy decisions about how wecan make still allow for alcohol
but try to protect populationsfrom getting into trouble, and
(28:24):
we are a population where we'reseeing more and more harms,
unfortunately.
So I do think at some pointthinking about some broader
level changes and, as you said,like maybe even thinking about
how we better make peopleunderstand, like how much
alcohol is in your craft beerbefore you drink it.
So you understand what's thatthe equivalent of right?
(28:45):
Is that the equivalent of onedrink?
Is it equivalent of much morethan that or not?
Dr. Megan Riehl (28:52):
What if the secret to feeling happier and
healthier lies in your gut?
It's true, your gut producesabout 90% of your body's
serotonin, the feel-good hormone.
That means what you eat and howyou manage stress directly
impact not just your digestivehealth, but your mood too.
For the 11% of people globallyliving with irritable bowel
(29:14):
syndrome, this connection islife-changing.
Ibs can feel overwhelming, butthere's hope.
Introducing Mind Your Gut (29:21):
The Science-based, Whole- body Guide
to Living Well with IBS,co-authored by GI experts, Kate
Scarlata, a GI registereddietitian, and Dr.
Megan Riehl, a GI psychologist,this guide offers a holistic
and evidence-based approach toreclaiming your life, with
targeted mind-gut techniques,practical nutrition advice and
(29:45):
gut-soothing recipes.
It's your complete toolbox formanaging IBS and feeling your
best.
Don't let IBS control your life.
Take charge of your gut healthtoday with Mind Your Gut,
available now in hardcover andaudiobook formats wherever books
are sold.
Can you share with us a littlebit about how the liver
(30:06):
metabolizes alcohol and how thatcomes to affect things like
fatty liver and cirrhosis thatyou've mentioned and hepatitis
things like fatty liver andcirrhosis that you've mentioned,
and hepatitis.
Ponni Perumalswami, MD (30:21):
Yeah, so alcohol is metabolized by
several processes in the body,what we call like metabolic
processes or metabolism, and itmost commonly involves two
enzymes.
One is alcohol dehydrogenaseand the other enzyme is aldehyde
dehydrogenase.
And these enzymes help breakapart alcohol as a molecule to
make it possible for the body toeliminate it essentially.
(30:41):
Alcohol or ethanol, right asthe body sees it, broken down
first by the alcoholdehydrogenase or ADH enzyme and
that's found in the liver andthat takes ethanol right into a
toxic compound calledacetaldehyde.
And acetaldehyde is thenusually not hanging out in the
(31:03):
body very long and it's quicklybroken down further to a less
toxic compound called acetate.
And that's done by the secondenzyme I just mentioned, the
aldehyde dehydrogenase, and thenfrom there acetate gets broken
down to carbon dioxide and water, mainly in the tissues outside
of the liver.
So it undergoes like thisprocess to kind of break it down
(31:26):
so that the body can eliminateit.
But, as I just mentioned, youknow it's a binge drinking
episode right, or heavy alcoholuse in nine out of 10 patients,
for example in the liver, willgo on to still develop hepatic
steatosis.
But this is largely reversibleas long as like that amount
isn't kept up.
And when it is kept up, that'swhen we run into the problems
(31:46):
with alcohol-related liverdisease and then all the
downstream complications that wenever want to see.
The other thing I'll say is,like there, so like in the liver
, for example, like alcohol,it's a dose and duration
dependent major risk.
It's predominantly driven right.
Driving the alcohol, but thereare other factors, including
genetic factors, environmentalfactors, we know women, things
(32:10):
like history of bariatricsurgery.
There might be lots of othergenetic factors, some of which
are known, some of which are notwell known, and then lots of
other factors that are stillbeing studied that we may not
completely understand as beingrisk or putting people at risk
to develop bad outcomes fromlike alcohol-related liver
disease.
Kate Scarlata (32:28):
Keep thinking about those gut microbes.
They're somehow factored in,right?
Yeah, so some people getdiarrhea, some people feel
really bloated, some people getheartburn.
What is it about alcohol thatcreates these symptoms for some
people, and do you think it'sdose-related?
What's going on?
Ponni Perumalswami, MD (32:46):
Yeah, so the alcohol, like I just said,
obviously can cause lots ofdisruptions along the entire GI
tract and a lot of thosedisruptions can happen very high
up in the GI tract.
So breaking down, you know, thelining of the esophagus, for
example, can then manifest asheartburn, right, and if we
scope some patients who haveheavy alcohol use, we might
(33:06):
actually see something calledinflammation of the esophagus or
esophagitis.
We also see these changes canhappen in the stomach very
commonly, right, the first kindof places where alcohol is the
body seeing, if you will, theesophagus and the stomach, and
in the stomach it can do thesame thing with breaking down
the lining.
So, again, if we were to do anendoscopy, some patients might
(33:27):
actually have inflammation ofthe stomach or what we call
gastritis.
Some people might actuallydevelop ulcers, right ulcers,
and that can put you at risk forthings like bleeding.
And so these things, like whenpeople say like, oh, my tummy
hurts or my belly hurts after Idrink, it could be related to
some of these changes happeningand then, like as you just said,
some people might get bloating.
(33:48):
Bloating might be relatedsometimes to type of alcohol,
person's gut microbiome, howthey respond to things, and
other people may not ever havethese symptoms.
So it's like quite a range thatpeople can experience, but some
of these might be just likemanifestations of the physical
changes right that are happening, particularly in the esophagus
and the stomach, which is thefirst place the alcohol is kind
(34:09):
of hitting in our GI system.
Kate Scarlata (34:11):
Yeah, I think at the end of the day it's a GI
irritant system.
Yeah, I think at the end of theday, it's a GI irritant.
I think it can be reallyirritating to the gut and known
GI irritants.
Dr. Megan Riehl (34:22):
So that was a really beautiful way to explain
how it is one Well, and I'lltalk with patients too about
what are your behavioral choicesif you've been drinking and if
you've had a night of drinking.
And then you get home and thenext morning you wake up to the
pots and pans out because youfixed yourself some mac and
(34:44):
cheese and more snacks and maybesome ice cream and where you
stopped at McDonald's in yourUber or spent $40 at Taco Bell.
All of those choices on top ofthe alcohol consumption are
going to be a bit problematicfor you the next morning or,
unfortunately, for a lot ofpeople with GI conditions for
(35:05):
several days, even after a nightout.
Ponni Perumalswami, MD (35:10):
So that is exactly like that concept.
It sounds like a briefintervention.
So after we ask about alcohol,right, we find out about how
much, and then patients come tous obviously reporting lots of
symptoms in the context ofwhatever other things we might
be seeing them for or managingthem for.
So brief interventions they'rea behavioral treatment and it's
all about having just like thisfocused conversation about
(35:32):
alcohol and potentially relatedharms or how it's like, maybe
involved in symptoms that theymight be reporting and really
aimed at trying to then getpatients to be motivated to
create a change plan around thatalcohol behavior.
And this is actually veryeffective in people with
unhealthy alcohol use, so noteven having a diagnosis of
(35:52):
alcohol use disorder and theneven in patients with mild
alcohol use disorder or moderateto severe, to get them then
engaged if needed to movetowards treatment.
So, yes, this brief focusconversation of the impact of
alcohol is very powerful and atool we should be leveraging a
lot more when we see patients.
Dr. Megan Riehl (36:10):
Absolutely.
I talk about that in terms ofthis bidirectional relationship
with patients that have anxietyand depression, where I'll ask
about what are some of thethings going on in your life,
what are your coping skills tomanage your mood symptoms?
And for the patients that sayyou know well, I have a drink at
night and it really calms medown.
(36:30):
It calms the anxiety.
I don't feel those symptoms ofdepression as much anymore,
there's a technique calledmotivational interviewing, where
we start to gather informationfrom people and not to shame
them or stigmatize them aboutthe choices that they're
engaging in.
But education can go a long way.
(36:51):
So with depression specifically,I'll talk about the facts that
alcohol can intensify yourdepressive symptoms, maybe not
in the moment, but certainlybecause you're disrupting the
brain chemistry and for somepeople it's also impacting your
social relationships and thestability that you feel at work
or at school, and so further.
(37:12):
Problematic it becomes when thebrain chemistry, which the
neurotransmitter thatspecifically comes up is GABA,
which promotes relaxation, andthen serotonin, which affects
mood, is disrupted by alcoholuse, and so over time the brain
then becomes less capable ofmanaging whether it be anxiety
(37:35):
or depression, naturally, whichthen leads you to more drinking,
which becomes this very viciouscycle and so helping patients
to understand that their alcoholchoice in the short term is
going to create longer termproblems.
And so let's talk about how wecan create some healthier habits
(37:55):
that will actually get at theroot of why maybe you are
turning to numb or to calm, andsome strategies like relaxation,
exercise, healthy socialconnection, making sure that
you've got a good medical team,making sure that you're open and
honest.
A lot of people that aredrinking alcohol are probably
(38:17):
living with shame or guilt iftheir alcohol relationship is
unhealthy.
So again, that's not togeneralize to all people
drinking alcohol, but if you'resomebody who wakes up the next
day and kind of feels some ofthat emotional sensation of oh,
what did I say last night, ordid I do something?
(38:37):
Or maybe you know I got behindthe wheel of a car and I
probably shouldn't have donethat last night, if you're
having any of those questioningthoughts, just make sure that
you start to talk about thatwith somebody and know that
there are available resources tohelp you.
Kate Scarlata (38:53):
Yeah, and I would say too, you know I've
worked with some clients thatcome in and say, geez, you know
I feel really bad on Monday,like the beginning of the week,
and come to find out they'reweekend warriors, you know.
So they're partying hard on theweekends and it really has
downstream effects to their gutand so we start seeing these
patterns and then you helpidentify the patterns to their
(39:16):
GI symptoms and they're morelikely to go oh aha, you're
right.
I probably need to really focuson that if I don't want to have
major diarrhea on Mondays.
Connect the dots as providersand certainly our listeners.
(39:39):
Hopefully you can also connectsome dots with your own personal
story and the way you're usingalcohol or not using alcohol.
What do you say to yourpatients about just ways to
mitigate specific goals for them?
What are some of the goals thatyou suggest to help them
decrease their alcohol?
There are certain techniquesthat you use in practice.
Ponni Perumalswami, MD (40:00):
So one is just like having a very open,
honest conversation, like aplace like where patients can
feel reassured that what they'regoing to get from me is lots of
empathy and like lots oflistening and then also help if
they're wanting it.
But it's also helpful for themto know, like how we can be
helpful, and I think a lot ofpeople don't understand or know
(40:22):
all the different ways maybe wemight be able to be helpful.
So obviously I see lots ofpatients who have an alcohol use
disorder in the context ofliver disease and so I always
make sure patients are veryaware of different types of
treatment we have for patients.
Making sure they know thatthere's both medications as well
(40:44):
as behavioral treatments youwere just mentioning.
You know cognitive behavioraltherapy, for example, is a type
of more intense, focused,skill-based therapy right.
To get patients to try to copeand change how they're using
alcohol to cope with problemsthat often kind of coexist or
co-occur and just occur reallycommonly for everybody in their
(41:05):
everyday lives If it's stress,it's anxiety, it's depression in
the context of having a boweldisorder or a liver disease.
So making sure they know thereare lots of tools we have in our
toolbox.
I find that, like a lot ofpatients might have a slice of
the understanding of what wehave to offer, even with
medications.
You know, the one medication Ifind, for example, everybody has
(41:26):
awareness about is likeAntabuse or disulfiram.
It's the one medication wenever give patients with liver
disease because of livertoxicity and so like then
talking about all the differentother medications we have, if
they're interested and howmedication and or behavioral
therapies can be helpful forsomebody who, in the context
we're talking about thesenegative maybe health
(41:47):
consequences or harms thatthey're experiencing, how these
treatments can be helpful and ifthey're not able to do it on
their own right, like that'swhere Medicaid but they want to
and really making patients feellike super centered in these
discussions is, I think, veryimportant, so that this is all
about how we can be helpful toyou and what do you want, how do
(42:07):
you want us to help you, andthen again asking about it, not
just once, but asking about itand offering treatment early
often and keeping patientsengaged around this discussion,
because they may not want itmaybe at the start of like wait
when you have this firstconversation, but after they're
(42:27):
building a relationship with youor they're seeing maybe other
negative health consequenceshappening.
You might just find the rightkind of window where patient's
motivation has changed, and Ialso really try to medicalize
this in a way.
I also let patients know 50% ofalcohol use disorder is
hereditary.
So in the same way that somepatients are diabetic but not
(42:49):
overweight or have high bloodpressure and are taking, you
know, need medications, oneperson might need medications.
Another person may not needmedications, might be able to do
with some diet and exercise.
That we want to have the sameapproach, that you know we have
treatments to offer.
And how do you want us to behelpful?
Kate Scarlata (43:08):
I love that.
I think too, like just this isyou know you're dealing with
people that are in it and have adisorder, and then there's the
other spectrum of people justmaybe dabbling a little bit too
much and you know, for thatcrowd I really try to get them
to think about have a seltzer,then have a glass of wine, or
(43:30):
have a spritzer instead of theglass of wine, or think about
some of the non-alcoholic beersthat are out there that are
tasty.
If you want to participate inyou know last call, but you
really don't want to have analcoholic beverage, consider a
non-alcoholic option.
There's so many cool mocktails,as Dr Riehl mentioned earlier,
(43:52):
that can feel festive and thatyou're part of the crowd.
Having seltzer with a littlesplash of cranberry and a lime
looks like a cocktail and youdon't have to deal with the
commentary.
So there are little strategiesfor those that are on the well I
really want to cut down, but Idon't have a liver disorder, but
I don't want to get one andaddressing those patients which
(44:15):
I see frequently they just needto dial it back and need some
tools to do so.
Ponni Perumalswami, MD (44:20):
Yeah, yeah.
So I think, yeah, we need toaddress people much earlier,
right before they develop.
And, yeah, making sure peopleknow that they have these other
options to have non-alcoholicchoices and to still feel like
they fit in in social settings,because that is a big part of
how alcohol is consumed.
It's really part of the socialfabric in a lot of different
(44:42):
cultures.
I also think, like highlightingwhat patients tell us right
after they cut back or they stop, even in those settings, that
they tend to sleep better, theytend to feel better, they tend
to have better personalrelationships.
So making sure we'rehighlighting all of the
potential positive things thatcan come right with making some
small changes, like, as you said, this summer I started kind of
(45:05):
exploring mocktails and myfavorite seems to be
transitioning well from summerto winter.
Dr. Megan Riehl (45:13):
I love a little ginger beer with a squeeze of
lime and then I just add to it.
So whatever else I want, if Iwant it a little spicy, I'll do
a slice of jalapeno.
If I want it more festive, Ican throw in some rosemary.
So maybe our listeners canshare their favorite mocktail
recipes with us too.
And I also then feel reallycomfortable with my kids seeing
(45:38):
me make this.
So they're observing, mom,that's putting something
together to drink.
That's not just water or coffeeor tea, but if they have a sip
of it, whereas if you have aglass of wine or something and
inevitably your child comes overand they pick it up and it's
like no, no, no, no, that's formommy, that's mommy's drink.
It's like if they want to try asip of it, sure you can have a
(45:59):
sip of this.
So certainly our relationshipswith alcohol are individualized
and personal, and if you needsomebody to talk to about it, I
encourage you to do that.
Hepatologists like DrPerumalswami are like you know.
You're right.
The empathy just exudes out ofyou and you create a safe space
(46:21):
for people that really allowthem to embrace their health
journey, and that's really whateverybody certainly deserves.
So with that, I just want tothank you so much for your
expertise.
Today we're all kind of lookingat this brand new year and
maybe rethinking relationships,whether it be with alcohol or
(46:43):
broader health and wellnessgoals, and we are here.
The Gut Health Podcast, Kateand I are going to be with you
all year long talking about ourgut health and really hoping to
inspire everyone along the way.
As we wrap up at this episode,we like to ask all of our guests
the following questions.
So, for the first time in 2025,Dr.
Perumalswami, what is somethingthat you prioritize when it
(47:09):
comes to your own health andwellness?
Ponni Perumalswami, MD (47:12):
I'm hoping to like be working out
more.
I would say, you know I'malways like challenged with
trying to figure out, you know,the balance.
I think I hear this a lot frompatients.
I'm also, you know, we're allpatients also too right In some
capacity, and so like I feellike eating healthier and being
more active is something I'malways trying to, particularly
(47:33):
not just in the new year butthroughout the year.
But recommitting in the newyear to trying to do so.
I just signed up for a workoutclass at our community center.
They're continuing it.
Yeah, so that's my commitmentfor the new year.
Dr. Megan Riehl (47:45):
You deserve it, good.
Kate Scarlata (47:47):
It's perfect.
It's so perfect.
Well, thank you so much forcoming on today.
Really informative.
I love your patient-centeredcare model.
Really today, reallyinformative.
I love your patient-centeredcare model.
Really important to The thepatient be the center of their
universe and their healthcare.
So thanks for all the work thatyou do and sharing your level
of expertise with our listenerstoday as we kick off our 2025
(48:09):
season.
So please make sure yousubscribe, follow and like The
Gut Health Podcast.
Your support means the worldfriends.
Dr. Megan Riehl (48:19):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at The Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
Popular Podcasts
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.