Dr Alan Desmond: Because whole grains overall are so beneficial and so crucial to human health, that telling someone to stop eating whole grains is actually a big, you know, a big thing to do. It's a really big intervention.
Dr Rupy: Without further ado, I want to just get straight into this podcast because we had an incredible conversation and I really want you to have access to all the information. I don't want to cut anything out of it. He's an incredible resource of information. There's lots of extra information that you'll find on the show notes as well. So, have a listen and let me know what you think. Let's get straight into it. I put a call out on Instagram just last night and I said, going to have a gastroenterologist on the show. We're going to do some rapid questions. So if you're up for that, I haven't actually done this on this podcast before, and I imagine it probably will not be rapid because we're going to end up, you know, going into a few things. If you've still got some energy.
Dr Alan Desmond: I'll try and keep it rapid if you want. We'll try and do it rapid.
Dr Rupy: We'll try and do it rapidly. Yeah. Okay, cool. So, I think we've already answered this question. Fibre, low or high, does it depend on your IBD severity?
Dr Alan Desmond: A small amount of fibre is advisable even for patients with active inflammatory bowel disease. So that might just be a small amount of fruit or even pears out of a tin or a puree is something. But if you're in the midst of a severe flare to the point where you're seeing your gastroenterologist and you're requiring high dose steroids or high dose intervention, then temporarily, yes, eliminating fibre can be helpful. But as I said during our conversation, I don't want that to extend it out forever.
Dr Rupy: Exactly. It's not a long-term plan. Exactly. Probiotics, prebiotics, synbiotics, are they safe?
Dr Alan Desmond: Okay, you've got three different things. I guess so prebiotics are these substances in food that we don't digest, but the bacteria in our tummies digest. So we can also refer to them as microbiome available carbohydrates. And they actually have a bit of a crossover with FODMAPs. They are healthy. So we get those from fruits and vegetables and beans and split peas and lentils. So those are a healthy thing. Probiotics are pharmaceutically prepared individual strains of bacteria that have been shown to have theoretical benefits and are then recommended for certain conditions. I don't recommend them globally for GI health. I don't tell people to take probiotics unless I'm in some very certain clinical situations in which specific probiotics have been shown to have some help. Every probiotic is completely different. It's a different preparation, a different bacteria in a different concentration. So speaking with inflammatory bowel disease in mind, there are one or two probiotics that I will prescribe in very specific situations for a limited period of time.
Dr Rupy: Yeah. And I think it's I always point this out to patients who come out with their specific bacteria strains that they're taking for a particular problem. It's really like putting a minute species into your gut, which is full of thousands of different species. So it's really like a teaspoon in the ocean.
Dr Alan Desmond: No, it's true, but that being said, we know that when we take a probiotic into our system, it passes through our gastrointestinal tract and in most cases, it leaves our gastrointestinal tract, but it does exert an effect. It does change the balance and it can change the diversity and it can change the balance of microbes in your gut. So the fact that they pass through our system and they're in small volume doesn't mean they've not done anything, but again, I don't recommend them in general for gut health, just in a few specific situations.
Dr Rupy: Yeah, I think there's an issue that we're having with people just taking probiotics because they hear it's healthy in a preventative manner almost.
Dr Alan Desmond: The international probiotic market, I can't remember how much it's worth, I think it's about 45 billion a year or something. So where there is big money, there's going to be big scientific claims, often unproven.
Dr Rupy: Probiotic foods, kefir, sauerkraut, kimchis, what do you make of those?
Dr Alan Desmond: Well, they are certainly beneficial in terms of improving our gut microbiome diversity and a healthy and diverse gut microbiome is a good thing. In inflammatory bowel disease specifically, there are some theoretical benefits, but we haven't seen the clinical trials bearing that out. There's been a few small studies. There was one in ulcerative colitis which showed that you could boost how much protective butyrate patients were producing, but it didn't make any difference in the clinical outcomes. So I don't recommend them as part of treatment. And in terms of general, generally taking them, I think they're a useful thing. They're a marker of a healthy diet. But it's sort of the plant-based icing on top of the plant-based cake because really the conversation I have often starts with, can you eat three pieces of fruit a day? Or can you include some vegetables at breakfast? So if we get down to should I or should I not include kimchi, then we're doing really well.
Dr Rupy: Yeah, exactly. I like that analogy, the plant-based icing. We already spoke about this, but what to look for if you are going to take a probiotic? What would you go for? What would you specifically look for?
Dr Alan Desmond: I'd look for the evidence base. Exactly. I would want to see some studies showing benefit.
Dr Rupy: We've polarized the conversation really to diet nutrition, but stress, emotional health and inflammatory bowel disease, do you feel that there is a link and what should we do about it?
Dr Alan Desmond: Well, we know there's a very real link between gut health and mental health. And the link between the gut and the brain is both physical via the vagus nerve and hormonal via the adrenal glands and the hyperpituitary axis. So yes, there is a very real connection between gastrointestinal symptoms and personal and emotional stress. And the extreme example of that, everybody knows, you get some bad news, you get a feeling in the pit of your stomach, or you might have to rush to the loo after you've seen something traumatic. And you know, so the gut and the brain are absolutely connected. And my patients tell me all the time at clinic, you know, my IBD is flaring up a little bit, but we've just sold the house, or I'm just going through a divorce. So that's very well documented.
Dr Rupy: Yeah, I certainly have patient anecdotes like that. I'm going through a stressful time and that's correlated with their flares in their IBD. Do you ever recommend certain meditation or stress relieving techniques at all?
Dr Alan Desmond: No, I really do. I mean, we're limited in the time we have to spend with people, but if it does come out that they're suffering from stress and anxiety, I mean, I'll just give them some basic tips. I had a conversation with a young chap recently who's going through a lot of stress, self-employed, moving house, issues at home, etc. I said, can you carve out 20 minutes a day just to go for a walk? And he said, he said, I don't think I can. And I said, well, can you carve out five minutes a day? Just get outside the house and walk around the block. And sometimes that's where that conversation starts. But I do sometimes recommend using meditation apps like Headspace or Calm as just a little entry point for people to take a little bit of time out.
Dr Rupy: You've got a stressful life, you know, you've got a full-time job, you've got young children. How do you relax?
Dr Alan Desmond: I do podcasts. That's a great answer. No, I try, I try to get a bit of exercise. I've been failing these last couple of weeks. I've been incredibly busy, but I do like to get out and run. I do like to get out on the water. I'm blessed to live near the beach. So I like to get out and row at the weekends when I can, but my attendance at the leisure rowing club recently has been poor. And yeah, I also use mindful meditation. So on a good stretch, I'll be doing 10 minutes a day.
Dr Rupy: Yeah, yeah. I struggle sometimes to maintain my meditative practice. And really, it's at the detriment of my daily life, really. I should be prioritizing that because I do prioritize exercise and obviously cooking. So, you know, it's just getting that three to five minutes in a day.
Dr Alan Desmond: Well, it's that old truism, isn't it? If you don't have time to meditate, then you really got to start meditating.
Dr Rupy: Exactly. Yeah, exactly. Managing inflammation with steroids. Is this something that you've come across that diet can actually have, obviously we've talked about diet, but is there any particular?
Dr Alan Desmond: Are we talking specifically about inflammatory bowel disease? Specifically with inflammatory bowel disease. Yeah, so steroids, corticosteroids are one of the mainstays of treatment. When we encounter patients with a new diagnosis of inflammatory bowel disease or if patients are having a flare of their inflammatory bowel disease, which is quite significant, we use corticosteroids to dampen everything down. And that treatment's been around for 60, 70 years and there haven't been many advances in it really. But the important thing about steroid use is that we use it sparingly. We only use steroids if we have to. And if we have patients who've needed two courses of steroids in a year, then we're really looking at other treatment modalities. And obviously we've got other medications, we've got immunosuppressants, we've got biologic drugs, but we've also got diet.
Dr Rupy: Yeah. Fasting and intermittent fasting and autoimmune conditions in general, but specifically for inflammatory bowel disease, have you found any evidence for those and would you ever?
Dr Alan Desmond: I haven't seen any studies. So I don't recommend anything unless I've seen a nice, well-conducted study, ideally performed at a centre for gastroenterology. And I haven't seen any studies showing benefits of intermittent fasting. And it would kind of fill me with a little bit of concern because I've already got patients with a digestive health issue who are having possibly having difficulty maintaining their weight or absorbing nutrients. So, you know, my gut feeling is that I wouldn't recommend fasting, but if someone shows me a great study that shows objective improvement, then then I would recommend it, but I don't right now.
Dr Rupy: I think specifically for patients with inflammatory bowel, the concern would be disrupting that mucin layer, encouraging your bacteria to worsen the epithelial structures and increasing the inflammation in the short term.
Dr Alan Desmond: No, you're right. So in theory, there's potential downsides, right? But we'll wait and see the paper. I'm sure someone's working on it.
Dr Rupy: I'm sure, yeah. Celery juice, is it worth the hype? I haven't heard of this. This is the first time I've someone just sent me a message, celery juice, I've heard it's amazing for colitis.
Dr Alan Desmond: I suppose in theory, I have seen papers showing that individual phytonutrients can be very helpful in inflammatory bowel disease, but I'd have to see the data. I'm not quite sure what the beneficial compound in particular is in celery juice. I mean, I obviously ask my patients to try and include some fruits and vegetables. If the only thing they can get is celery juice, then that's fine. So be it, but I don't have a strong opinion.
Dr Rupy: Yeah, no, I've heard some similar things with aloe vera juice as well, but I haven't got.
Dr Alan Desmond: So aloe vera has been studied for inflammatory bowel disease and the results are disappointing, so I don't recommend aloe vera. I do sometimes recommend curcumin or turmeric extract for ulcerative colitis.
Dr Rupy: This is very interesting actually, because there was a gastroenterologist I spoke to at St. John's Hopkins and he said to me, curcumin and boswellia for him is just like a no-brainer. It's unlikely to do any harm. I don't know with these patients, but it's potentially useful in inflammatory bowel.
Dr Alan Desmond: It is, particularly for ulcerative colitis. So that's one of the few traditional remedies that's been well studied in ulcerative colitis and it's been the subject of at least three randomized control trials. So we've seen two studies, one showing that curcumin, I think it was three or four grams per day, can be very successful in inducing remission in patients with mild to moderate flares of ulcerative colitis. And another study showing that it might be helpful in terms of maintaining remission. And in fact, the European Crohn's and Colitis Organization back, gosh, it must be 2012, endorsed curcumin for maintenance of remission. When they made that endorsement, it was on the basis of a Cochrane review that had said that it might be beneficial. But when those, when that Cochrane review happened and when the European Crohn's and Colitis Organization endorsed curcumin, actually the more impressive papers hadn't yet been done. So even since their endorsement, there's been more impressive papers coming out. So yes, when I have patients who have a bad flare of ulcerative colitis and things are getting a little bit serious, I will recommend it.
Dr Rupy: Any particular dose or brand?
Dr Alan Desmond: Well, the studied doses were three to four grams, and I try to get my patients to get curcumin where it's the single ingredient rather than a combined preparation.
Dr Rupy: Yeah, and there's no particular curcuminoid, it's rather the whole turmeric in a capsule, is it? Or is it curcumin?
Dr Alan Desmond: No, it's curcumin specifically. So the studies that have been done used curcumin.
Dr Rupy: Colonic irrigation.
Dr Alan Desmond: Please don't do it. I'm so glad. I get asked this all the time and I keep on telling people, what we know about the microbiota, it doesn't make any sense.
Dr Alan Desmond: No, it's counterintuitive, isn't it? The other thing that...
Dr Rupy: Sorry, colonic irrigations for people who don't know, are where we introduce an enema into the intestine and it's essentially washed out and the thinking is we are cleansing the bowel.
Dr Alan Desmond: I suppose technically you are cleansing the bowel, but if you wait six or seven hours, your bowel will cleanse itself.
Dr Rupy: Gluten and gut health. This is something that's been the subject of a few papers that came out, I think from Scripps University where they introduced an autoimmune protocol based on some of the autoimmune diets that are floating around the internet. Similar in the whole food diet plant-based approach, but with specific regard to removing dairy and gluten with some positive results actually looking at CRP. What is your opinion on that?
Dr Alan Desmond: So I guess we already have a few distinct entities with consumption of gluten. People will be familiar with celiac disease, which affects about 1% of the population. So they cannot consume wheat gluten, also in barley and rye. We've got a phenomenon of actually being allergic to wheat, which happens in less than one in a thousand people. That's a genuine life-threatening allergy. And then we have this phenomenon of non-celiac gluten sensitivity, where people feel unwell if they consume wheat and gluten. Now, when that's been studied, that probably occurs in just about 1% of the population. And for many of the people who feel that wheat and gluten is causing their symptoms, often it will be something else. So it's worth seeing a gastroenterologist, having a chat with your doctor, having the blood test for celiac disease, and then maybe asking yourself those three questions about fruits and veg and whole grains and trying to clean up your diet in general. But in terms of inflammatory bowel disease, there is some, there is some information out there. There are some studies out there that show that celiac are, excuse me, some studies out there that show that gluten consumption may aggravate the inflammatory process. And under the microscope, there's certain common features between celiac disease and Crohn's disease. But the evidence isn't convincing enough that you would tell someone with inflammatory bowel disease to remove whole grains from their diet, because whole grains overall are so beneficial and so crucial to human health, that telling someone to stop eating whole grains is actually a big, you know, a big thing to do. It's a really big intervention. But some of the studies, such as Ari Levine's study, and even our own study that we're hopefully recruiting to in January or February, where we've got patients who are in the midst of a flare, during the first six weeks, that protocol, it will be gluten-free, but then one of the first things we'll be getting our patients to reintroduce will be whole grains.
Dr Rupy: That's really interesting. Alan, I think we've really gone, we've gone deep on inflammatory bowel. I know we've covered so many topics and we've, we've done a marathon session. So thank you so much for coming down. Would you mind, I'm sure all of our listeners want to know where we can find you on social media and your website. That'd be great.
Dr Alan Desmond: Yeah, if you, if you want to read my random evidence-based musings on gut health and all things plant-based diet, you can find me on Instagram at Devon Gut Doctor.
Dr Rupy: So you're based in Devon and you're a gut doctor.
Dr Alan Desmond: That's at Devon Gut Doctor.
Dr Rupy: It's a great name, Devon Gut Doctor. Definitely go check it out.
Dr Alan Desmond: Yeah, and my food looks, well, nearly as good as yours. Nearly as good as yours.
Dr Rupy: We'll do a few collaborations on recipes, I'm sure. I'm sure. Yeah. And your website?
Dr Alan Desmond: Well, my my own clinic website is devongutclinic.com, but I'd also encourage your listeners to check out the homepage of Plant-Based Health Professionals UK. So that's pbhp.uk. So that's a charitable organization set up to help educate patients and medical professionals on the benefit of a healthy plant-based diet. We had a very successful conference in London this year and in Glasgow, and we're planning another one for Warrington, April 13th. So get over there and get your tickets. And I'd also like to plug VegMed 2019.
Dr Rupy: VegMed 2019. When is this?
Dr Alan Desmond: Well, we're helping to organize that with ProVeg. So that will be Europe's largest scientific conference on the benefits of a whole food plant-based diet. And that's on in London, October 12th and 13th. The first day is a scientific congress for health professionals. The second day is a public day.
Dr Rupy: Fantastic. I can't wait to go. Thank you so much again. And all the show notes and stuff that we've been talking about will be on the website, the doctorskitchen.com, and I'll catch you soon.
Dr Alan Desmond: Thank you.
