The Role of Gut Microbiome in Sleep Quality and Health: Dietary Strategies for Microbiota Support

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:19):
Thank you.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.

Dr. Megan Riehl (00:34):
Hello friends, and welcome to the Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Dr Megan Riehl, a GI healthpsychologist.

And I'm Kate Scarlata, a GI dietitian.
We have a very exciting podcastfor you.
Today.
We are talking about sleep.
We all need it and some of usare better at maximizing our
sleep quality than others.
Sleep also plays a key role inmaintaining our physical and
mental well-being.
It can influence our hormonelevels, mood, appetite and even

(01:10):
our weight.
And guess what?
It profoundly affects our guthealth.

It's really fascinating, and as adults, we
will spend an average ofone-third of our life sleeping
ideally depending on whateverlife stage you're at and so we
better try and do it as well aswe can, Kate, and I like to say
you know, buy the good sheets,make your bedroom a beautiful
oasis.

(01:36):
And today we have a trueinternational rock star from the
sleep world joining us.
Dr Cathy Goldstein is aprofessor of neurology at the
University of Michigan in theSleep Disorders Center.
She holds several leadershiproles within and outside of the
university, and if you wear adevice that has some degree of

(01:57):
sleep tracking, she has probablyresearched it.
Because get this.
Dr Goldstein's research usesthose sleep tracking devices and
mathematical modeling to assesssleep patterns and circadian
rhythms in the real world, ourday-to-day settings, and this
informs research in the area ofwomen's reproductive health, MS

(02:19):
and gastrointestinal conditions.
She is a true powerhouseeducator across a variety of
learners, including physicians,peers in the sleep space,
University of Michigan, athletesand coaches, and you might even
recognize her from features onCNN, with the New York Times and
Time.
Dr Goldstein, my dear friend,welcome.

Dr. Cathy Goldstein (02:43):
Thank you so much for having me both of
you.

We are so excited , so we always start our podcast
with a little myth busting,because there's a lot of
pseudoscience out there.
So what myth bust would youlike to share with our audience
pertaining to health and sleep?

Yeah, I think one of the biggest ones
that I probably encounter everyday in clinic at every family
event is that melatonin helpswith insomnia, and that is
probably the biggest myth thatwe try and fight in the sleep
world.
Insomnia has never been shownto be due to a melatonin

(03:23):
deficiency.
Melatonin is something ourbodies secrete.
It's our signal that it'snighttime and it's time for
things to wind down and go intothat quiescent mode.
So taking melatonin exogenouslyis really, really not the
cure-all for insomnia.
It's great for things like jetlag or, if you're a severe,

(03:44):
severe night owl, something wecall delayed sleep-wake-based
disorder, but insomnia is reallydue to problems that we can
have behavioral interventionsfor.
So we do things like we mistimeour sleep, we go to bed too
early, we reduce our sleephunger or what we call our

(04:04):
homeostatic sleep drive, bysleeping in and napping.
We have a lot of maladaptivethoughts that arise when we
start being unable to sleep.
So we catastrophize theconsequences of a night of poor
sleep, and then, on top of that,we added behaviors like well,
if this is going to be such adisaster, I'd better spend a
long time in bed trying to sleep.

(04:26):
And then we form an associationwith the bed and wakefulness.
We use substances thatinterfere with our sleep, like
caffeine and alcohol.
So there's so many othertargets, but we really really
like that idea of oh, ifmelatonin is what's secreted
when you're falling asleep, Ineed to take melatonin from
Target or CVS.

(04:46):
So I hope everybody can takethat home and kind of revisit
their relationship withmelatonin.

We'll certainly dive into that, and so I guess
we're starting our episode todaywith information that is not
uncommon on The Gut HealthPodcast, where a pill is
probably not going to be theend-all, be-all to your problem
and we probably have to work asa team to get things optimized

(05:13):
100%.

I think we have a lot of overlap in our
areas there.

Well, let's dive into that overlap.
So your husband just happens tobe a gastroenterologist at the
University of Michigan, and soI'm sure there's some
fascinating dinner tableconversations regarding the
intersection of neurology andgastroenterology.
Give us a little insight intothe Hiatt-Goldstein dinner table
combo.

Yeah, and I wish I could tell you this is
something very esoteric andintellectual, but I think anyone
on your podcast who's listeningthat there's two healthcare
providers usually sit down atthe table.
It's like what's the weirdestthing you've seen today.
But things that we've kind offound more interesting and

(06:00):
systematically have come up is alot of times.
Our gastroenterologists arefolks that detect patients'
obstructive sleep apnea.
So people are really good abouttheir preventative healthcare
or primary care docs will getfolks in at midlife for their
colonoscopy and they get thatsedation and they hear snoring

(06:22):
pauses in breathing.
People are dropping theiroxygen and they hear snoring
pauses in breathing.
People are dropping theiroxygen and so our GI docs
actually often refer these folksto the sleep clinic.
So sometimes people don't evenhave any symptoms and they end
up because of the colonoscopyfinding.
So that's kind of wild.
And then we've both just alwaysbeen very impressed with how

(06:42):
mental health bleeds in to bothclinical areas, so so much.
And mental health impacts allsystems in our body and can
overlap with any chronic healthdisorder.
But we've both been soimpressed how it shows up in GI
symptoms and sleep symptoms evenwith larger magnitude than

(07:04):
anywhere else.

Early in my career I did some pilot research
with Cathy and kind of thatinsight and I found it to be
fascinating as a GI psychologistthat so many of my patients
were suffering with sleepdifficulties.
So yes, it certainly bleedsover and our way in which we
help people manage thesecomorbidities really requires

(07:28):
that dream team.
And we have a guest.
Dr Goldstein's cat has joinedthe podcast and we love animals
around The Gut Health Podcast.
So welcome to.
.
.
I can't remember that one'sname.

Yeah, and that one actually has
inflammatory bowel disease fromthe vet.
So here we go.
It comes full circle.

There we go, there we go.
That is so funny.
There are so many factors thatimpact sleep.
What are some of the top thingsyou see in your practice that
are really affecting people intheir sleep patterns?

The biggest thing that we take care of.
The most common thing thatpresents to sleep clinic is
obstructive sleep apnea.
So obstructive sleep apnea is adisorder where there's
repetitive closure of the upperairway during sleep, at the
level of the back of the throat.
When this happens during sleep,your lungs don't fill with air,
your oxygen levels drop andyour brain wakes up and tells

(08:23):
you to breathe, and so patientscome in and they're waking up a
lot.
They feel sleepy during the day.
But we also know that thisdisorder can increase the risk
of high blood pressure, diabetes, heart disease and worsens GERD
symptoms, and so it's really,really a significant problem,
and we used to think this was aproblem in obese middle-aged men

(08:47):
.
We now know it could be inwomen, thin people, children,
and I still get surprised everyweek when somebody I thought had
insomnia or even narcolepsy.
Actually it's all due toobstructive sleep apnea, and
CPAP has gotten a bad rap,unfortunately, over the years.
But CPAP truly is the besttreatment for obstructive sleep

(09:11):
apnea, and a lot of myths existamong our patients Like, for
example, you're giving me theCPAP machine.
That's just covering up theproblem.
Why don't we just get to thebottom of this and do surgery
and take out my big tonsils andmy big uvula, and the reason
that that doesn't work iskeeping your airway open at
night is a really complexproblem and it's not just having

(09:36):
big tonsils or a big tongue ora big uvula, but it's also our
brains control keeping ourairway open.
It's also the muscles in ourairway, and so we have really
complicated conversations inclinic about this and with
education we really are able tomove the needle on getting
people to use CPAP to treattheir obstructive sleep apnea

(09:57):
and once that benefit andsymptoms is seen that
improvement in sleepconsolidation at night, that
improvement in alertness duringthe day, reduction in GERD
symptoms, drops in bloodpressure in our hypertensive
patients we really see peopleengage with their treatment and
that's huge for us.
The other biggest condition thatwe see in clinic is insomnia,

(10:21):
and the type of insomnia that isthe most common is something
called psychophysiologicalinsomnia, which is a mouthful,
but it's a really niceexplanation of what it is.
So for some reason, someonewill start developing difficulty
sleeping, or they've alwaysbeen predisposed to being a
light sleeper and then theystart developing these

(10:43):
maladaptive habits and behaviorsthat start to perpetuate their
mind going and, going and goingat night, or what we call
cognitive hyperarousal.
So to cope with the difficultysleeping, people will spend
extensive time in bed.
They'll develop these reallycomplex wind down routines where

(11:04):
they start worrying about sleepwhile they're like out to
dinner.
What am I going to do when Iget home?
I need to get the check so Ican start my bedtime process.
And this is really whatperpetuates that cognitive hyper
arousal.
This I'm tired, but I'm wired.
And then these individuals spendso much time trying to sleep

(11:25):
that they start to associate thebed with wakefulness and it's
just a complete downward spiral.
And the best treatment for thisis from our behavioral sleep
psychologist and it's calledCognitive Behavioral Therapy for
Insomnia and it works betterthan any sleeping pill on earth.
That's not just an opinion,there's actually trials and it's

(11:47):
a really important treatmentthat I think any patients with
insomnia can benefit from.
And again, it's kind ofbreaking some of these habits.
So even if you're somebody whohas insomnia, but not to the
extent you presented to clinic,like if you have insomnia, don't
start going to bed earlier.
If you have insomnia, don'tsleep in on the weekends so you

(12:09):
can catch up on sleep.
These are things thatperpetuate the problem and
there's a lot of myths out thereand perceptions regarding how
to improve insomnia.

Yeah, as a health psychologist, there are
some basics of things that Ioffer, and one of the first
things I start with is justgetting an idea of what are you
doing of things that I offer.
And one of the first things Istart with is just getting an
idea of what are you doing inbed.
I always highlight that the bedis for sleep and sex.
That's it.
It's not our dinner table, it'snot our desk for work.
It's really only supposed to befor those two things.

(12:40):
And to your point that therebecomes this anticipatory
anxiety of I've got to get tosleep.
So I'm curious just basics,because I always find this, I
remind myself this sometimes,even if I'm kind of having a
difficult time with a couplenights of sleep what is a sleep
cycle?
How many do we go through in anight and when do we get our

(13:03):
most restorative sleep?

So this is a fascinating topic.
So sleep cycles and sleepcycling refers to how we
progress through the differenttypes of sleep throughout the
course of a night and we enterour sleep through non-REM stage
one sleep, which is very lightsleep, and then you go into
non-REM2, and that's a bitdeeper.

(13:26):
We start seeing synchronizedactivity in different parts of
the brain that we can pick upwith our brainwave measurement
or EEG.
And then we go into non-REM3sleep, and a lot of people have
actually heard of this, but notby that name.
They've heard of this as slowwave sleep or deep sleep, and
this is the type of sleep thatyou can think about.

(13:48):
It's the metabolism of yourwakefulness.
That's what's the marker of howwe get rid of that pressure of
being awake.
That grogginess that ensues isour non-REM, slow-wave sleep.
And then we go into REM, and thecrazy thing about REM is that
REM looks entirely differentthan the other stages.
So you lose that synchrony ofthe brainwaves.

(14:10):
It kind of looks likewakefulness.
Your eyes are going up and downwe can actually see it in our
sleep studies and so you have avery active brain, active eyes,
but the rest of your muscles areparalyzed, except for your
breathing muscles.
So it's fascinating and wedon't fully understand why we
have these different stages.
It's just something that hasbeen observed.

(14:32):
Once we started recording sleepand we parsed them out into
these different names.
But clearly they all havedifferent purposes.
So when people ask us, usuallybecause they've tried to measure
their sleep stages that they'rewearable.
I'm not getting this stage.
I'm not getting that stage.
Is that why?
my memory is falling apart.
I tell people all sleep stagesare required to be restored and

(14:55):
alert and cognitively intact.
You can't just have one or theother and also we can't
preferentially really increasedifferent sleep stages.
There have been some gadgets onthe market to increase slow
waves and also we can'tpreferentially really increase
different sleep stages.
There have been some gadgets onthe market to increase slow
waves, but there are these bulkyheadbands.
I would think in the end theydisrupt your sleep overall more
than they help.
So it's really making sureyou're getting appropriate sleep

(15:19):
as a whole and not pressuringyourself to hit one sleep stage
or the other.

All right.
So before I get started with mynext question, I just want you
to describe what a CPAP machineis, because some of our
listeners absolutely know whatyou're talking about.
But I did want to have thatlike quick definition what is
this machine?
So that listeners canunderstand what you were talking
about a moment ago.

Absolutely so.
CPAP stands for continuouspositive airway pressure and
it's a machine that I would sayit's roughly the size of a
shoebox.
That positive airway pressuregoes through a tube and the
tube's about six feet long.
It's flexible, it's made out ofmedical grade latex and then to
a mask, and the masks either gointo the nose, just over the

(16:04):
nose, or over the nose and mouth, and we really rarely use the
infamous Darth Vader masks thatpeople often associate with CPAP
and are concerned about using.
We use much smaller, lowprofile masks.
And then that air pressureprevents that airway collapse
that we see in obstructive sleepapnea Snoring.

(16:28):
A lot of times people arewondering well, where does
snoring fit in this?
Just because you snore doesn'tmean you have obstructive sleep
apnea.
But most people withobstructive sleep apnea will
snore and snoring is areflection that the airway is so
relaxed that it's vibrating andit makes that snore sound.
And the CPAP machine will getrid of that as well.
So bed partners tend to loveCPAP.

(16:49):
It makes like a little quiet,white noise, which is much
better than snoring, choking andgasping at night.

I think so.
For sure.
Okay, let's dive deeper intothe impact of sleep on our gut
and its health.
Can you speak to how our gutmicrobiome may play a factor
into sleep and vice versa?

So I think kind of the first thing to think
about when we think about sleepand GI health in general is
what's been found in the lastfew years is that sleep
disturbance are really reallycommon among patients who have
GI disorders.
So if you look at IBS inparticular, 72% if you survey

(17:34):
them have poor quality sleep ingeneral.
That's really really high.
Sleep disturbances are commonacross adults in general.
But 72% we don't even hearnumbers like that in medicine
with anything 50% have insomniaand 40% take sleep aids.
So a really large percentage ofthis population is struggling

(17:56):
with their sleep and we knowwhen they have insomnia, when
they're sleep deprived or whenthey're sleeping at the wrong
time or have circadianmisalignment, which means a
mismatch between when yourbiological clock wants to sleep
and when you're actually gettingsleep.
So think of like a night shiftworker or somebody who has a
naturally very late clock, who'sa night owl but has to get up

(18:19):
very early for work.
These are ways you can disruptyour circadian clock and these
worsen the expression of GIdisorders.
So this can worsen pain andsymptoms in IBS.
This can increase the risk offlares and IBD.
So this is really critical.
These disorders kind of impacteach other, the gut itself, like

(18:43):
the tissues of the gut.
What's surprising is theyactually have their own
biological clock right.
So our biological clock thatfor a long time we thought the
machinery for that was in thebrain only.
Actually, almost all the cellsin your body have that clock
machinery.
So things aren't just happeningat random times of
physiological processes and thecell processes.

(19:05):
They're really reallyexquisitely timed.
So, as you can imagine, if yourgut has a natural clock, you do
not want to be eating pizza atthree in the morning.
This is going to cause problemsand we know that that's the
case.
And when you disrupt the clockby behaviors like that, you're
not only disrupting yourperipheral clock in your GI

(19:27):
tract but you also can havemisalignment of your central
clock.
So these things are very, very.
We say the brain is kind of theconductor and this is a very
complicated orchestra.
The microbiome, again verycircadian driven.
So all those microbiome, allthose organisms, those also have

(19:48):
their own clock machinery andif the individual, the host
where that microbiome lives, ifthey have circadian disruption.
Again, think of things likenight shift work, jet lag and
potentially even what many of usdo, which is something called
social jet lag, where we go tobed later and wake up later on

(20:09):
the weekends.
That can all cause circadiandisruption, and when the gut
microbiome has circadiandisruption, those organisms tend
to move towards a moreinflammatory profile, and so
that could be one of the ways wesee increased risk of all kinds
of disease cardiovascularmetabolic in people who have

(20:29):
circadian disruption.

Yeah, it's really interesting because I've read
about like bacterial metabolites, due to even dietary changes,
may impact sleep patterns andthat people with sleep
disruption have different typesof microbiomes that appear to be
more dysbiotic.
So we're really like startingto piece out some of this
microbiome piece.
And I think of my GI patientsyou know that maybe have the

(20:55):
pizza, maybe not even at threeo'clock, but maybe 730.
And they have so much gas andbloating and triggering of their
GI symptoms that certainly theydon't feel very calm just to
relax because they're fightingoff a battle within.
So there's that component aswell, right?

Absolutely and one of the biggest.
And unfortunately as sleepproviders we're not great at
educating our patients on this.
But a lot of times my patientswill come to me and they'll say
I moved my dinner up by twohours and my sleep has changed
dramatically and so kind of evenindependent of that circadian

(21:35):
clock and thinking of things ata molecular level, but just
eating at that later time andthen becoming recumbent.
We find that if people movethat earlier, at least four
hours before bedtime at leastand I've had when people go even
earlier they get better effects.
It really really can have animpact on sleep.

Yeah, I mean that makes sense, right, because our
gut microbes are responding tofood and they're responding to
fasting, and so I think, inaddition to calming the gut,
you're also probably changingmetabolite production at the
time.
Maybe that you're, you know,should be having some shut eye.
So I can't wait for them tokind of dig this data out a

(22:18):
little bit more into likeclinical pearls.
We're not really there yet, butit is really fascinating.

Absolutely.
And you know, with GERD one ofthe things that we've seen is
that even if people don't havethe symptom of acid reflux, gerd
can disrupt your sleep.
So they've done a lot ofstudies in GERD.
They're far beyond in the GERDarea than they are in the
microbiome at this point andthey looked at sleep overnight

(22:46):
and all these different arousalsfrom silent episodes of acid
reflux.
So that alone really, reallyshould act as a precipitant for
people to move those mealtimesup.

Totally agree, we're thinking like people that
have poor sleep may need to talkto a gastroenterologist, and
then you know patients that arepresenting to their
gastroenterologist with some ofthese struggles, whether they be
gastrointestinal or other waysin which they're feeling
symptoms in their body.
The path looks moreholistically and sleep is really

(23:18):
at the core here that it's hardto do anything well in our life
, whether it be thinking, eating, participating in our
day-to-day activities, if we'renot sleeping well.

Yeah, and what really you reminded me of
just then when I'm thinkingabout the patients that you see
and treat.
Lack of sleep, sleepdeprivation, is hyperalgesic.
So if you are not gettingenough sleep, you're
experiencing pain in a moresensitive way, wherever that
pain is coming from.

So if it's in your muscles, if it's in your
joints or if it's in your GItract, that's a huge point to
make for people that arestruggling, and what I do think
is really empowering is that wecan optimize sleep right.
We can work on this.
It's just a matter of just theway in which we help people with
gut issues recognize that it'softentimes multifactorial.

(24:12):
It's not just maybe an organicissue or a functional issue.
Oftentimes there's anutritional piece, there's a
stress piece, there's a mentalhealth component.
So to that point, I talk withmy patients a lot about the role
of stress and anxiety on theiroverall health, but specifically
, they're typically coming to mefrom a gut health perspective.

(24:34):
So what are some of the from agut health perspective?
So what are some of the reallyimportant factors related to
stress and mood on sleep thatyou talk with your patients
about?

Obviously with clinical diagnoses anxiety,
depression we do see prettyprofound sleep disruption.
But if we kind of move a littlebit more proximal to that and
look at just kind of generallife stressors, these obviously
are going to impact the sleep.
And the biggest thing we see ifsomebody is undergoing a
stressful season, particularlyif we're looking at sleep in

(25:09):
midlife they can fall asleepokay, but they can't stay asleep
.
And we know it's very normal towake up at night.
Waking up like three times isnormal.
But what becomes abnormal hereis the inability to fall back to
sleep.
And then it's nice and dark andquiet and every stressor
concern, anxiety or worry comesout at this time and people lay

(25:34):
in bed thinking about thesethings, trying to problem solve,
worrying, and then that causesthe association with bed and
wakefulness and stress and itperpetuates insomnia.
So the best thing to do whenpeople find themselves in this
situation is to get up out ofbed, leave the bedroom and do

(25:55):
something relaxing in dim light.
Leave the bedroom and dosomething relaxing in dim light.
I really find in general andthis almost gets outside of the
sleep world and more into theperformance and productivity
world that adults don't do agood job.
Planning right.
We get in the day, we openOutlook, we see what our
calendar looks like and then weopen our email and start putting

(26:19):
out fires.
No one has a broader plan fortheir month, their week and
their day.
So I really encourage people.
People often ask me because I'min the tech space.
They're like what's yourfavorite sleep gadget?
And I'm like it's an app calledEvernote where I plan what I
need to do and I can dojournaling.
I plan what I need to do and Ican do journaling and that's

(26:42):
what I would love to see peoplemake part of their day.
We always say good sleep startsin the morning and so it's
really working to get thesethoughts down, get these worries
down and how you're going todeal with them.
Think about what projects youhave for the week, for this
month, for this quarter.
So you have a plan.
So you're not making that planat two in the morning when you
can't return to sleep.

Right, and this really, really does help.
It's stress management.
It's anxiety management.
Whether you have an anxietydisorder or not, we all have
day-to-day stressors andactually in our book, Mind Your
Gut, we talk about a strategycalled constructive worry.
That is outlined you can checkthat out in our book.
But just briefly, it speaks toyour point of taking some time,

(27:28):
a couple hours before gettinginto bed, to think about what
are some of the stressors that Ihave going on, what are some of
the fires that I want to putout, and in the wakeful hours of
the daylight, maybe, being ableto reach out for social support
or to touch base with somebody,follow up things that we can't
do in the middle of the nightand we have more resources

(27:51):
available to ourselves in ourwaking hours and you come up
with some plans and strategiesthat then, when the little light
in your brain goes off at 3 am,you're able to kind of go no,
no, I thought about that problem, I thought about that stressor,
I've got a solution for it andwe're more likely to be able to

(28:11):
fall back asleep.

And we recommend the exact same thing.
I'm so on board with that.
I wish more people would dothat.

Yep, well, they will, now that they're
listening.

And I have to say that I do that now because of
writing the book with Dr Riehl.
I am one of those people thatwakes up and starts thinking
about everything and then I getnervous that I'm going to forget
the thing that I was justremembering.
And if you do that pre-workbefore bed, two to three hours
before, you can just knock thoseworries right off the table

(28:43):
while you knock back to sleep.

I also like a mindfulness practice to
overlap with this too.
Right, and I think one of thegreat things about mindfulness
and combining it with somethinglike scheduled worry or
constructive worry is that youcan give yourself permission in
the middle of the night.
That's just a thought about astressor.
I already dealt with that and Ithink that's because people

(29:09):
have a lot of perceptions aboutmeditation.
And I'm not a Buddhist and howcould I do this?
I'm not a Zen person.
I like my anxious thoughts.
For me, that's not whatmindfulness is about.
It is about giving yourselfpermission to recognize that
real.
That's going on as justthoughts, and now you have an
outlet to deal with them that isoutside of the sleep period.

So one more tip and trick that we can give to
people tonight is that when youget into bed, notice your
posture.
Are you curling up into a ballwith your hands clenched and
your shoulders up by your ears?
And that's how you're startingyour sleep night.
I always love people to thinkabout starfish.
Sleep starfish, where you openeverything up, you pull your

(29:55):
shoulders down, you open yourhands wide, you give yourself
the cognitive self-talk of I'mgoing to allow myself to let go
of the stressors of the day, I'mgoing to relax my body.
I'm going to notice how thatfeels, and so starting your
night with relaxation will allowyou to.

(30:16):
Then, however, you get intoyour comfortable sleep position
is fine, but you've made aconscious effort to activate
that parasympathetic system,your body's relaxation response,
which is going to cue you upfor a better night of restful
sleep.

Absolutely.

I like that.
I'm going to definitelystarfish this evening.
There you go, there you go.
So as a GI dietitian, you knowI like to think about how diet
may play a role, and we've kindof broached this a little bit
about timing.
Any thoughts on just fibereating, a nutritious diet,

(30:55):
modifying healthy fats, thatsort of thing.
Is there any diet connectionsthat you've read about as a
sleep expert and what yourecommend maybe to your patients
?

Yeah, the most we have is indirect at this
point.
We want people to have healthydiets in general so that being
overweight or obese, whichimpacts your sleep, is less
likely to be a problem.
The timing is huge.
Again, we don't know as muchabout the components, but the
timing is huge.
We do like for the evening mealto be a lighter meal but

(31:33):
contain some protein and orfiber so that people can remain
kind of full.
Right, we don't want people.
It's a balance between nothaving like actually physically
full stomach and going to bed,but also not being hungry as
well.
One of the most interestingthings we've seen about diet and
sleep is that a ketotic dietcan improve sleepiness, even in

(31:56):
our patients with narcolepsy,which is amazing.
So that you know, the ketoticdiet has profound effects on the
brain.
They use it to treat epilepsyand it might be a target for
disorders of sleepiness as well.
And I even tell my patients andyou know this is more anecdotal
Everyone has a dip after lunch.

It's a physiological response, and so I
tell all of my patients makesure your lunch isn't filled
with carbohydrates and see howthat improves, and we get a lot
of benefits from that, lookingat various diets and sleep,
whether it be even narcolepsy orepilepsy, there are different,

(32:40):
probably microbiome features inpeople with those conditions
that may benefit more so fromdifferent types of diets too.
So it's hard to give sort of ageneral one-size-fits-all with
diet.
Would you agree with that?

Oh yeah, and we know so little at this
point.
We know as far as true datagoes.
I mean, I'm just working to getour patients to a more healthy
diet in general, so that'softentimes our biggest goal,
because a lot of the people Itake care of are quite obese.
So we're looking to work withour nutritionists for both

(33:17):
increasing that quality of thediet and then also reducing the
caloric intake.

Sounds good.
One thing that pops into mymind again, kind of our dream
team approach, of the importanceof the physician, the
registered dietician and thepsychologist, is for our
patients that have gut problems,avoiding food all day long, so
that they can get their tasksdone, so that they're trying to
avoid the symptoms, the GIsymptoms.

(33:43):
And then to your point it'sreally counterproductive to have
your largest meal at the end ofthe day, where sometimes people
feel safe, like okay, I'm home,I'm not leaving again if I have
urgency.
But again we'll talk about oneexample or one demonstration
that I'll give with patients andyou can correct me if I have
urgency.
But again we'll talk about oneexample or one demonstration
that I'll give with patients andyou can correct me if I'm wrong
, but I'll say okay.
And then you go, lay down andthink about the body.

(34:06):
The body wants gravity to workwith it and so you've put all of
the calories of your day andyou're laying down and it's
harder to go through thatdigestive process.
That's where we see peoplewaking up with nausea and gas
and bloating and GERD and thesewild fluctuations, and when
they're having bowel movements,and so again it becomes

(34:28):
behavioral of moving those meals, spreading them out, but also
so critically important to workwith a dietician to find those
foods that are gentle on yourgut and that are going to get
you back into that rhythm thatwill help with the circadian
rhythms of both your gut andyour brain.

Yeah, the body is not equipped to handle
food at night, it's just not.
And then we've completely andremember, it takes so long for
people to evolve, so we are notbiologically evolved with how we
live in this society, which isgo, go, go during the day and
then we're going to go home atnight, we're going to relax in
front of a screen and eat food.

(35:09):
That's not what your body ismade to do.
Your body is made to live witha farmer.
You should be eating when it'sright outside, really primarily.
That's when your largest amountof food intake should take
place.
That's when your body is bestequipped.
And they found, when youcalorie control, people, even on
the same diet, depending onwhen they time their food intake
, the individuals who time itmost with breakfast are going to

(35:31):
lose more weight.
But I understand why peopledefinitely make those changes
because of fear and that youknow.
That's something I shouldactually start asking my
patients.
Are you avoiding eating all daybecause of your IBS, eating at
night, and that's what's causingyour insomnia?
And that's where there canreally be a lot of collaboration
in our field.

No, definitely, because if you can calm the gut,
you'll sleep better.
If you're sitting therewrangling with gas and bloating
and abdominal pain and trying toget to sleep, it definitely can
be a lot more challenging.
I know you mentioned melatoninNot that beneficial, probably.

(36:12):
Are there any supplements atall, or is it really lifestyle?

Actually there was a very large
meta-analysis looking at all thesupplements that have been used
in sleep valerian, melatonin,all of these things and none of
them work.
So really the only supplementso melatonin and circadian
rhythm disorders, so jet lag,shift work disorder if you're a
night, severe night owl.

(36:40):
Really the only supplement isiron, and the only time we would
use iron for sleep is ifsomebody has restless leg
syndrome, because iron is acofactor of dopamine.
We think changes in dopaminetransmission cause restless legs
, people with restless legs.
So that's the urge to move thelegs in the evening and you

(37:01):
can't settle down, can't fallasleep at night because of that.
These patients have been foundto have low central nervous
system iron and so that's reallyit's very non-sexy.
That's the only supplement thathas really been identified over
and over again to improve sleep, but it's in a certain context.
Magnesium has some data.

(37:21):
It might improve general sleepquality and it might improve
restless leg syndrome as well,but it's pretty minimal.

Okay, so just to go back to the melatonin in
those certain subsets of peoplethat may benefit, how much is
recommended?

Again, it definitely depends on the
context, but when we're usingmelatonin in a way that's an
evidence base, what we're doingwith the melatonin is we are
trying to move the clock.
We are not trying to knockpeople out.
We are trying to move theirbiological clock earlier,
typically with the use ofmelatonin.
And so that requires that themelatonin is given at a very

(37:59):
precise time and it has to behours before your body's own
melatonin starts.
Otherwise it's like sitting inthe ocean, like taking melatonin
when your melatonin is beingsecreted does nothing.
So, for example, say you'resomebody who has severe delayed
sleep, weight phase disorder.
You sleep great from 4 am tonoon, but that obviously doesn't

(38:22):
work with your job.
So I'm moving your biologicalclock earlier.
I want to give you melatonin atleast a few hours before your
own melatonin secretion begins.
And someone that falls asleep,well, at 4 am, their melatonin
secretion begins at 2 am.
But I don't want that melatoninto bleed into the wrong part of
the clock.
So we give half a milligram toone milligram.

(38:45):
Have you guys ever seen half amilligram melatonin at the
checkout shelf at Target?
Never, nope.
Three, five and ten.
And we know that those amountsof melatonin increase the body's
own melatonin during thedaytime exponentially.
So we just really don't like it.

So the majority of people are taking this
completely wrong.

Way too much, yeah.
And then the other thingthere's all this variability.
Like the melatonin may saythree milligrams, but it could
vary wildly the amount ofmelatonin that's actually
included in that supplement,because these aren't regulated
by the FDA.
Once you take melatonin for along time, you have down
regulation of your melatoninreceptors in your brain, so we

(39:27):
really have no clue what's goingon.
And the problem with manythings that I deal with and you
guys deal with is the solutionsare simple but they're not easy.
And one of the best things youcan do as a first step for your
sleep, if you're struggling withsleep quality, insomnia at
night, is to start waking up atthe same time every single day,

(39:48):
seven days a week.
And that's really not as fun asmelatonin that's in a cool
bottle or comes with an app oryou know so, but these are kind
of the heart.
Your body is biologicallyprepared to do what it's
supposed to do.
Right, we are biologicallyprepared to sleep.
We've known in the history ofsleep medicine is like actually

(40:09):
missing one of these parts.
Right, people have intactcircadian rhythm and homeostatic
sleep regulation.
But our behaviors oftentimesare acting in opposition to that
biology.
Right, and it's not somebody'sfault.
The behaviors make sense.
They're adaptive mechanisms,but we really have to strip
those down to let your ownbiology work.

(40:30):
And again, it's not a melatonindeficiency.

So interesting.
I do want to just talk a littlebit about the iron, okay,
because I don't want thelisteners to think, oh, run out,
get an iron supplement,especially people that are
challenged with constipation.
I was going to say bind yourright back up.
Yes, so if they have restlessleg, this is really a specific

(40:54):
patient population you'rediscussing.
How do they talk to theirphysician about the connection
with iron?
Like, what does the listener dothat has restless leg that
might say, hmm, what do I dowith this?

Yeah so, and even our primary care
doctors are usually our firstline of defense with this.
They're all very well aware ofthis problem.
So when we talk about restlesslegs, we talk about urge.
So I have an urge to move thelegs, so that's the U.
It occurs at rest, so that'sthe R.
It gets better with movementand it's more pronounced in the

(41:32):
evening.
Okay, so those are the symptomsyou're looking at with restless
leg syndrome.
And when you go into the doctoryou should have iron studies
done.
But it's important.
They're low, but they're still.
In.
The normal range is when wesupplement.
So we supplement for ferritinlevels of 75 and below and iron
percent saturation of 20% andbelow, but above that you're not

(41:58):
really going to absorb the iron, you're going to get
constipated.
There's some people that mighteven be predisposed to iron
overload.

Okay, that's excellent.
I wouldn't start iron withoutiron labs.
Thank you, that's reallyimportant information.

And I've got one more.
We live in Ann Arbor, it's hot,we can pop into the dispensary
for any and every ailment.
What about the THC CBD productsout there that people are
swearing by?
Are really getting them thatgood sleep?

Yes, I mean , it's been a miracle for us.
I'm surprised we have anypatients anymore, because I hear
it cures everything.
But okay, here's what we know sofar and I will tell you
anecdotally a lot of my patientshave good luck with them.
Sleep is really hard becausethere's a very large placebo
effect.
But the placebo effect if it'sgetting you sleeping.

(42:49):
There's a lot of push-pull withthis, but what we know
scientifically is that, yes, THCdoes seem to promote sleep.
When we're looking at sleep asdefined by EEG during the sleep
study, the problem we see isthat when people use
THC-containing products toofrequently and the cutoff seems

(43:09):
to be about five times a week,it's almost like alcohol, where
their insomnia starts gettingworse, likely due to some type
of withdrawal or dependencyphenomenon.
So if people do use it, yes, itmight help your sleep.
However, if you use it too much, it could have the opposite
effect.

Okay, so from the mouth of the world-renowned
expert, with just anotherconsideration yes, and also, yes
, your body's made to sleep.

Leverage your biology.

Leverage your biology.
I love that.
So, all right, I want to talk alittle bit about the wearables
now and from this consumer space.
There are lots of devices outthere for sleep tracking, many
coming to the market all thetime, and actually you just had
a review article in the journalSleep that came out this year,

(44:02):
and it highlights that thedevices they give us
opportunities opportunitiesbeing key for continuous,
unobstructive and large-scalesleep monitoring in those of us
in our kind of sleep environment, right at home in bed and it's
fascinating what these thingssay, that they are tracking,
like breathing rates, skintemperature, something called

(44:25):
cardiac autonomic indices, whichcan include, like heart rate
variability.
So tell us what you found inyour research about the wearable
devices, because, again, peoplebecome desperate for sleep, and
so, if it means shelling out acouple hundred dollars for a
device, what are the pros, whatare the cons?

First thing .
So these devices?
One of my favorite people inthe field they kind of the same
thing.
Yes, what you measure, you canimprove.
But just like a scale is notgoing to necessarily make you
lose weight, neither is awearable sleep tracker.
And the other thing is that,because these are so ubiquitous,
my goal is to make everybodylike a wearables expert no

(45:08):
gatekeeping.
So I want all your listeners tounderstand how these work.
So these devices, so my patientalways comes in they say say, my
watch doesn't get this muchsleep.
I'm like well, your watchactually doesn't measure sleep.

They're like what are you talking about?
Yes, it does it, says it itsays it on my app.

Yeah, these devices measure cardiac
activity and they measure motion, measure cardiac activity and
they measure motion and becausewe know what happens to your
cardiac activity and your motionduring sleep in a normal person
, in a normal setting, thatcardiac activity and that motion
activity is then modeled byalgorithms to determine when

(45:49):
you're asleep or when you'reawake.
So, as you can imagine, this isnot something that's going to
work well in certain patientgroups.
We don't know how these work inpeople with pacemakers, afib,
sleep apnea probably affects theperformance of these devices
and we really have to make surewe know what we're measuring
here, which we're measuringsleep.

(46:10):
So sleep is coming from thebrain.
We're measuring sleep in theperiphery.
We're measuring, kind of, thecardiac emotion output of sleep.
So one of the most importantthings in sleep disorders, right
, is the mismatch between theintent to sleep and the actual
sleep.
So if you are someone whosleeps seven hours, we have two

(46:35):
patients that sleep seven hours.
One person goes to bed at 11 pm, gets up at 6 am, one person
goes to bed at 9 pm and gets upat 6 am.
The difference between thosepatients is clinical insomnia
now and they're getting theexact amount of sleep and that
is the importance of the intentto sleep.
And what do these devices notmeasure?

(46:57):
The intent to sleep.
So I find these are very limitedin the exact population that
wants to use them, which is ourinsomnia patients.
And the other problem is thatthey misclassify non-moving
wakefulness as sleep too.
They have a tendency to do thatbecause emotion is part of the
input and also our heart ratedrops when we're at rest.

(47:18):
So currently and this isn'tsomething humans used to do we
flank both the bedtime and waketime with these and,
particularly at bedtime, verylong periods of non-moving
wakefulness because we'rewatching Netflix, we're
scrolling through our phones andagain, that device has no idea
if you're trying to sleep or not.

(47:38):
Dropping heart rates, no motion, that's sleep.
So we have to be very, verycareful about what we're pulling
from these devices and theycannot tell you how well you're
sleeping or if you're happy withyour sleep.
So this is how I recommendthey're being used, because
you're going to say this is likeyour thing, that's made your
career, and you're tellingpeople.

(47:59):
So the only time I recommendthat people use these for their
sleep is you really want to makesure you're going to make a
change based on it.
Like I'm not feeling well, Iwonder if I'm devoting enough
time to sleep.
That's a great thing that youcan pick up on these devices

(48:19):
because the device, like I said,it thinks sometimes non-moving
wakefulness is sleep.
So if you're consistently sixhours on that device, you're
probably way less right.
So if you're somebody whothinks they might need to extend
their sleep time, that's agreat way to use these devices.
Also, if you want to do somewhat we call end-of-one studies,

(48:39):
how does alcohol affect mysleep?
How does exercise affect mysleep?
How do dietary changes affectmy sleep?
You comparing you to you, notthe average percentage of REM
sleep by a 30-year-old male,right you comparing you to you?
The problem with these devicesand some of the patients that
tend to use them who haveinsomnia they can worsen anxiety

(49:02):
, worsen insomnia.
They've even coined a name forit, called orthosomnia now,
where people are relying more onwhat the device is telling them
about their sleep than how theyactually feel.
And then the other thing sorry,I could talk about this forever
I want people to keep in mindbecause one of the biggest
things that people get upsetabout when they're looking at
their data isn't that they'regetting this many hours of sleep

(49:24):
.
It's that sleep stage breakdown.
Sleep stages are EEG orbrainwave constructs.
We actually didn't even come upwith the sleep stages until we
were able to measure brainwavesduring sleep.
Right, they're a completeproduct of that.
So, even though it could end upbeing something that's
incredibly valuable theprediction of sleep stages

(49:46):
because we know there'sdifferent cardiac autonomic
changes during sleep stages andthat's how your Apple Launcher,
fitbit, is trying to predictthem and that might end up being
a really relevant thing but atthis point we don't understand
the relevance of it and I cannotpreferentially increase your
day-to-day REM sleep.
So that is not a good use ofthese devices and people really

(50:08):
want to look at them for that.
They really want to hit thiscertain target and it's just not
.
It's not a good use of yourtime.

So interesting.
Orthosomnia Is that what yousaid?
Orthosomnia, yeah.

Well, and you know I'm thinking about our
orthorexia population thatbecomes just obsessed with
health and eating and health,you know.
And so again, I can see a bigoverlap here of having some
tangible device that, like yousaid, you're paying more
attention to the device thanactually asking yourself how am
I feeling?
Do I wake up, feeling rested?

(50:42):
Am I sleepy through the day?
Am I moving my body?
All of these kind of indicatorsof health.

And people will completely ignore those
things but will be fixated onthe fact that my device says I
get 10% of REM every night and Ijust don't know what that means
yeah, there's some healthdisparities too for some of
these products, and research too.

I just want to mention that too.

This is like a huge thing for me.
Right now there is amillionaire no, he's probably a
billionaire and one of his bigthings is sleep and he put out a
sleep routine and I love anysleep in the media.
Anything that makes peoplethink about sleep I'm happy
about, but there's a lot ofpeople that can't.
He recommends his last mealtakes place at 11 AM.

(51:28):
No stressful substances, butalso no stressful environments
at all in the hours leading upto bed.
I don't need a fancy coolingmattress.
We do not want sleep andhealthy diet to be luxury items.
These are things that should beequitably available to all
people, and sleep is just not aluxury item, and that makes me

(51:51):
so upset with when people thinkthey need a gadget or a
particular mattress to have goodsleep.
I think that's like the worstmessage that we can send.
We want everyone to have goodsleep, especially our most
vulnerable populations.

Yeah, wow, I also think you know, just to Megan's
point and to your point as well, just the whole relying on
devices, relying on specialthings, really moves you away
from just listening to your ownbody cueing in and that is so
vital with nutrition, sensationsof being full versus overeating

(52:27):
, feeling restful and feelingless anxious, and all those
positive things that you canjust tune into without requiring
special products.
Yeah, 100%.
So I just want to talk a littlebit about just sleep and sleep
through the lifespan and youknow I love to talk about the

(52:49):
perimenopausal, menopausal womanwith hot flashes, but there's
so many things that can impactour sleep, from being a young
parent to, you know, stressfulsandwiching between young kids
and older parents.
What are some tricks fordifferent lifestyle phases?

I love this question so much, and no one
has ever asked me this on apodcast.
So I think this is a great waythat we don't typically think
about sleep interventions,because we kind of think of,
like pediatric people are overhere, the adult people are over
here.
All these things are good forsleep, but I do think, like you
said, given your life stage, wecan target different things to

(53:31):
focus on.
When you think aboutadolescence, it's actually a
really interesting time forsleep really interesting.
So for your listeners that haveteenagers and they're just going
through this right now.
So when kids get through pubertythere's a phase delay in the
circadian clock.
So they biologically it's notthat just that they I mean they
also do want to be a whole nighttalking to their friends and

(53:51):
playing video games et ceterabut they biologically also
become later.
So I think a great sleepintervention to focus on in
adolescence is really thatavoidance of light in the
evening time when we know thatlight at that time can push the
clock later.
And we're all pretty savvyright now about understanding

(54:14):
the role of screens, making surethat we're cutting off screens,
which a lot of times is notreally possible.
But all of our ambient light isalso blue enriched at this
point right now because we haveLED lights right.
So I think teenagers are greatto put these orange, blue
blocking lenses on.
You can get them on Amazon.
We use the UVex Skyper ones inresearch and putting these on a

(54:37):
few hours before bedtime,particularly because your
teenager's homework is going tobe on a computer, really can
help mitigate that biologicalphase delay in adolescence and
also making sure they're gettinglots of morning light.
I have two sons.
They like to be in thiscave-like environment, and so
they just love me because, ifit's, light outside, I'm opening

(54:59):
all the blinds, we're turningthe lights on and then vice
versa, once the sun goes down,I'm with my dimmer switches
going around the house, and sothat population is really,
really important to take a lightas a target.
Love that.
One of my favorite groups todeal with sleep is individuals
who have kind of just enteredthe workforce.

(55:19):
So they're usually still superhealthy, but they have really
bad habits, and their worsthabit with sleep is they have
that social jet lag.
So they can still kind oftolerate some sleep deprivation.
So they're waking up reallyearly during the work week.
Weekend comes around they startstaying up till 3 am and

(55:40):
sleeping in, and then on Sundaynight it's essentially like
we've flown from LA to New York.

Sunday Scaries.

Sunday Scaries.
They literally talk about it onreality shows in this age group
and part of the Sunday Scariesis because you know you're going
to have insomnia because you'vedelayed your body clock and now
you're going to try and go tobed at 11 in anticipation of
that 6am wake up time.
So my biggest recommendationfor that group to focus on is,
on the weekends, waking up nolater than two hours later than

(56:13):
your workday wake time.
So that's kind of our cutofffor social jet lag.
And if you're tired, take a napin the middle of the day.
That won't disrupt yourcircadian rhythm as much.
But I always am recommendingthat with that group.

How long can your nap be?

Oh, 30, 45 minutes.

That's okay, that's okay, that's perfect
Midlife.

What I see come up is what we talked about
a lot at the beginning of thispodcast that tired but wired,
it's quiet, it's dark.
So I'm going to think aboutwhat I need to bring in for my
kids' school, the project I haveto do for work, et cetera, et
cetera, and for that group Ithink that's scheduled, and what
did you guys call it?
Constructive worry or strategicworry?

(56:57):
Scheduled, constructive worryis huge, and this is also a
period of time where peoplestart getting so, so busy in the
evenings, and what I hear froma lot of my parents with younger
school-age kids, even teenagers, teenagers is that nighttime is
the only time I get to myself,right?

(57:18):
So what happens?
You take a population that Imean perimenopause can start in
your late 30s, 40s, right?
So you take this populationthat might already be having
some biological changes that aregoing to predispose to insomnia
.
They want to stay up late sothey can have their time.
So they watch Netflix on thecouch and proceed to doze off.

(57:39):
Then they go to bed and theycan't sleep, and I see this so
much.
So what I would love forself-care, instead of staying up
late and dozing off in thecouch, is for people in midlife
to really start thinking aboutintentional bedtime routines
instead of just dozing off.
When they doze off and I knowwe have to do a lot of kind of

(58:01):
pro cons because people say theylove this time I'm like I
promise you're going to be moreproductive the next day.
I'm giving you back time byhaving you have a planned
bedtime and going to bed earlierinstead of dozing off on the
couch.
I think dozing off on the couchand a regular wake up times in
the morning are two of the worstsleep habits that we have.

Hi, it's me.
I'm the problem.
It's me.
I just self-imposed a 10:30bedtime two weeks ago.
Because I wasn't dozing on thecouch but I was going into my
bed and I was not constructively, I was just scrolling away.

You were winging it.

Yep, I would find okay, it's 11, 11:30.
And I'm like this is not mybedtime, I can't be going to bed
.
Who am I?
What am I thinking?
So us in the field, we have todo these things too.
As providers, we caregivers, wehave to take a look sometimes.
And you know what, I'm all thebetter for it.
10:30.
I love it.

That makes me so happy.
And then I think about as weget older.
So you know, you're gettingolder, you can focus more on
sleep, but as we age, sleep canbecome a problem.
You can focus more on sleep,but as we age, sleep can become
a problem.
So as we get older, we'redealing with menopause in women,

(59:22):
we're dealing with healthconditions that can disrupt the
sleep, but even just in general,the sleep becomes less deep,
the sleep lightens and the sleeptiming also becomes earlier,
right, so people tend to fallasleep.
Great.
But they're getting up at fourin the morning and we know that
exercise is good for sleep inall people.
But exercise has really gooddata in older individuals and

(59:43):
improving the sleep, especiallyafternoon exercise, can increase
that slow wave and deep sleepthat gets less in amount as we
age.
And then the other thing I liketo augment that afternoon
exercise period with is anevening after dinner walk,
because that light and activitycan help our older patients from

(01:00:04):
falling asleep too early, andso I think that's a great
intervention in our olderindividuals to help with sleep
time quality.

Kate Scarlata (01:00:12):
Hello, that's me.

Dr. Megan Riehl (01:00:17):
Well, and I don't know if you've seen on the
internet, there's a womanthat's professing about the fart
walk, and so there we go.
We'll tie that in that aftereating, you know, before bed,
getting out, moving your body,getting out your toots it's a
healthy thing to do.
Moving your body, getting outyour toots, it's a healthy thing

(01:00:37):
to do, yes, so you know, Ithink that's the true tie-in of
gut health and sleep is, youknow, our physical activity and
letting our body, you know,naturally release its gases so
that you can get your Zs.

Exactly and not release it in bed.

Dr. Cathy Goldstein (01:00:52):
I think we know the name of your next book,
ladies, and I'm excited to getyour help with that Exactly and
not release it in bed.
I think we know the name ofyour next book, ladies, and I'm
excited to be able to help withthat.

We have a new co-author, Kate.
I love it, Cathy.
We have learned so much fromyour expertise today and as we
wrap up this episode that weknow our listeners are just
going to love and learn so much.
We like to ask our guests thefollowing question.
So, Dr.
Goldstein, what is somethingthat you prioritize when it

(01:01:20):
comes to your own overall healthand wellness?

I think she's going to say sleep.

Botox! Botox! No, I am a huge sleeper.
I'm a nine-hour sleeper atnight.
But probably the biggest thingfor me is exercise.
It's my coping mechanism forstress.
I feel like I'm very sensitiveto not having it.
I tore my ACL and had surgeriesand basically went bonkers

(01:01:51):
after that surgery.
So I have to move every singlemorning.

Move.
Allow yourself a good night ofsleep.

I move my body and not my face and not
your face.

That is my premise for self-care.
Love that I love it, I love it.
Well, thank you so much thiswas incredible.

I learned a lot and I know our listeners will
definitely learn a lot.
So thank you so much for comingon.
We appreciate it.
So to our listeners make sureyou subscribe, follow and like
The Gut Health Podcast.
Your support means the world.

Friends, thanks so much.
Thank you for joining us as wegrow 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,
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Thanks for tuning in, friends.

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