Dr Nina: Actually, it is not normal to have a 50-year-old with 20 medications. It is not normal to be crippled by chronic pain every day. It is not normal for women to have crazy painful periods and be told it is part of a woman's job. No, absolutely not. So we need to, I think, cut through that and say what we're aiming for is, whenever possible, optimal wellbeing is going to look very different from one person to another, but this is why we personalise our care, right?
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. Root cause medicine is a term that gets bandied around a lot, but on today's episode, you're going to learn about exactly what it means. Complicated conditions like PCOS or autoimmune thyroid disease actually have multiple causes and getting to the root of what is driving that process is essentially the aim of integrative medicine. And at the Personalised Medicine conference this year, I got a chance to sit down for an hour and chat with Dr Nina Fulascheva, an integrative medicine doctor, scientist and educator with degrees in medicine and natural sciences from the University of Cambridge, as well as an ongoing master's in precision cancer medicine at the University of Oxford. It is so refreshing and unusual to speak to somebody who comes from a science and nutrition background who then goes on into practising medicine, which is how Nina's career has progressed. She's also the co-chair of BSIO, the British Society of Integrative Oncology, with over a decade's experience in integrative health. Nina also holds multiple qualifications in nutrition, functional medicine, health, herbal medicine, yoga, mindfulness and other therapeutic approaches. She's the founder and director of Synthesis Clinic in Hampshire, specialising in women's health and integrative cancer care, for which she won a prestigious Innovation Leader of the Year award at the UK BIA 2022 for her inspirational vision for healthcare. Today's show is going to be a fantastic overview of how personalised medicine is used in her clinical consultations, how Nina uses therapeutic tools for both metabolic and hormone disturbance, the use of food as medicine, specifically black cumin and selenium, and her personal experience of integrative cancer care. Remember, you can download the Doctor's Kitchen app for free to get access to all of our recipes with specific suggestions tailored to your health needs. We're adding new recipes every single month and we are working on new health goals as well. And in the meantime, particularly for Android users, which we are working on very, very hard, you can check out the weekly Eat, Listen, Read newsletter. Every single week, I send you something to eat, something to read, something to listen to that will help you have a healthier, happier week. On to the podcast. Nina, thanks so much for taking the time to chat with us on the podcast today.
Dr Nina: It's lovely to meet you.
Dr Rupy: Yeah, I've heard you've been prescribing my books to many patients as well, which is so lovely to hear.
Dr Nina: I have indeed. We have a lending library at the clinic. So we have a whole variety of books, anything from yoga, emotional wellbeing, cookbooks, Dr Rangan Chatterjee's books. And so we lend it out to patients to help educate them and help empower them to make the changes in their lives and then they bring it back and it goes to someone else.
Dr Rupy: Oh, that's so cool. I'm so glad I'm part of that library. So thank you so much. It's just really put a lovely spark at the start of my day. So let's talk about the broader picture of this one-size-fits-all approach that we currently have in medicine. What, you know, we're talking about personalised medicine today, integrative care. What is the move towards personalised medicine? Why is personalised medicine so important?
Dr Nina: Well, to me, I think we're finding that the more complex and chronic disease we have, the more that our old way of approaching it with one-size-fits-all acute model of care doesn't seem to be working very well. And the more complexity and polypharmacy and polymorbidity that we have in the world, the more we actually need to individualise those guidelines that we have, all have as doctors and we all practice, and actually think about what are the unique root causes behind some of these things, so we can unplug multiple diseases and disease processes with actually looking deeper and personalising our approach. But also looking at not trying to treat everything with the same brush. So for example, if a person comes to you and that's their first presentation as you'd usually see in GP, you know, they have high cholesterol, for example, or their first presentation of high blood pressure. If we intervene at that point in a personalised way and actually look at their nutrition, lifestyle and contributory factors, instead of just giving them a pill for it, we might potentially prevent the development of all the other metabolic syndrome features. In women's health, which is where I practice, someone's PCOS and endometriosis can have different drivers depending on what their unique presentation is. And therefore, treating them all with the same hormone medications or surgery until the cows come home really doesn't yield people good results. And we also know that most of these complex diseases like say PCOS and endometriosis or autoimmune disease, they affect multiple systems in the body. So it doesn't actually make sense to treat just the presenting system. It makes sense to go deeper, look at the root cause and tackle it, try and to unplug the whole process, and then we're actually going to affect multiple physiological systems in the body. And that's what I see with my patients every day.
Dr Rupy: Yeah, yeah. And I think the way we talk about this and the way everyone in our community talks about this is almost as if everyone understands that, but it's still a very novel concept that we're trying to sort of push out into the masses. And I think one of the pushbacks that I've certainly got from both colleagues and patients is that it's very confusing. There's lots of sort of words being used in the vernacular that you hear about are integrative care, personalised care, functional care, precision care. What are the broad sort of terms that we tend to use interchangeably and how do we define exactly what we mean by those terms?
Dr Nina: So I think integrative medicine to me means the marriage of the best of all worlds. So the best of conventional medicine, which is as personalised as possible, and ideally is aimed at the whole person's needs rather than just a sticky plaster approach. But also combining the best of conventional medicine with nutrition, lifestyle, psycho-emotional wellbeing and evidence-informed complementary therapies. So that's a very broad toolkit that we can draw on and that's certainly how I practice at the clinic. Now, functional medicine and precision health, there's definitely a crossover between those two. And actually, I am trained in functional medicine, but I describe myself as a precision health doctor because I take a broader view and an integrative medicine doctor because that's my toolkit. So functional medicine is root cause-based approach, which I know you've had Dr Marvin Singh and you guys talked about that a little bit. And precision health kind of almost zooms out of that a little bit. And health and medicine, of course, are the other things we often use interchangeably, which are really not necessarily. So precision health really looks at all of the drivers. So it starts off with maybe genetic antecedents, so looking at someone's family history, looking at someone's maybe snip backgrounds. Of course, masses of work going on in Genomics England, looking at some of the rarer disorders, there's lots of population-based studies that are looking at that. And looking at how everything you do and the whole exposome that lands onto this genetics then creates health or disease. And that allows us to deliver personalised care. So to me, precision health or functional medicine, which is a kind of, I guess, a smaller sit-in within that, allows me to have a lens within which I view a case. So it's really important. The precision health is a broad approach. Within that, functional medicine looks at all the different systems, looks at the person's timeline, and then we can actually unpick all of those bits of hubs of pathophysiology to actually affect the whole person's wellbeing. So I feel like precision health and functional medicine are quite difficult to sometimes separate, but to me, precision health is broader. And also, of course, we always aim within both approaches to increase engagement of the person. We give people agency, and that's what we're all about. It's not about the old-style dictatorial approach of going, I tell you to take a pill, and you might walk out of there knowing why you're taking that pill or why bother. And as we know, compliance with medication is a big issue overall in people. And then you walk out of there going, okay, well, I've learned nothing about my health, so I'll just take a pill and it's easy, right? It's easy to do. And when people tell me that nutrition, lifestyle medicine or precision health is kind of a light approach or a non-invasive, I'm like, it's the most invasive thing you do because actually you get to change the whole life of a person to promote their health and wellbeing. But the results you get are so much more than what I've ever seen when I was working just purely in conventional medicine, just doing the pharmaceutical side of things. And I think we kind of, just like Dr Chatterjee said yesterday in his speech, we kind of got away from the purpose of medicine in the world and why we got into it in the first place. And to us, I think all of us doctors, this wasn't just so I could be a clever prescriber, right? It was that we wanted to make a significant difference to people's health and wellbeing and see transformations. And that's quite often we get worn down, certainly I did when I was working in hospital medicine, get worn down by going, I just prop people up and send them out and they're going to be back in four to six weeks and you're kind of not making enough of a difference. And we've got to, I think, change what's acceptable in medical care. I think it's a little bit like being in institutionalised environment of any kind. I mean, I'm going to be a bit controversial here, but it's a little bit like being in a cult, right? Everything is a bit crazy, but because everybody else is in the same situation, we accept that that's normal, right? Actually, it is not normal to have a 50-year-old with 20 medications. It is not normal to be crippled by chronic pain every day. It is not normal for women to have crazy painful periods and be told it's part of a woman's job. No, absolutely not. So we need to, I think, cut through that and say what we're aiming for is, whenever possible, optimal wellbeing is going to look very different from one person to another, but this is why we personalise our care, right?
Dr Rupy: Isn't it crazy how we have to preface what you just said with you being controversial? Like, I don't, it's, you're right, it's just so far removed from reality or what reality should be, the fact that you have to preface, I'm going to be controversial. I don't think these people should be on 20 plus medications. Isn't that crazy?
Dr Nina: But it's acceptable, right?
Dr Rupy: It's acceptable. Yeah, it's accepted. And I completely understand what you mean. We are in a very much a culture of that being the norm. And because we see it so often, it desensitises yourself to it. And when you step out of that into an environment like we're in at the moment, where we're talking to colleagues and we're talking about personalised medicine and that becomes the norm, you realise just how far removed we are from what really the optimum way of treating should be with patients. You mentioned agency there. I want to lean into that a bit more. I think this is almost like a forgotten area of medicine because agency and actually getting your patients on board is so important for the entire journey from disease to wellness or improvement along that. How do you engage patients in that, in that journey?
Dr Nina: I think I'm always going to almost going to slightly turn it around. We're saying, okay, we kind of want to engage patients in their journey. I think we need to actually not be afraid to let them drive that journey to a certain degree. I think as doctors, we kind of have this power differential, which I know Rangan talked about in his introductory speech yesterday. And I think we need to take the ego out of it, like he said, and I'm very passionate about it. And we need to be a partnership. And I think a partnership is the strongest way of encouraging agency, actually, and helping support people because to me, it is a partnership. If you're going to tell someone to that they need to change their nutrition or their lifestyle, you need to be a partner. You can't, I say to my patients, I can't eat for you, move for you, sleep for you, or do your mind-body work. Okay, I cannot do those things for you. I can be your support, I can be your expert guide, and I can provide you with the resources, but how you do this is up to you. And actually, while to some people that might be, they say, oh, okay, that's scary, it's my responsibility. I'm like, actually, with enough support, small changes, bite-sized changes that we can really personalise to you, the person gains their confidence in managing their own health and wellbeing. And I think in our current medical system, we've ultimately disempowered our patients massively. It's always been this model of going, I will give you something that will make you feel better. I'm a doctor, and I know about this and you don't. And as we know, this dynamic has been shifting massively overall. And so patients will come better informed anyway. They do want to have a say in their care, they want to have a discussion with you rather than have something handed out to them. But also more than that, we've got to remember that when we in medicine, we underestimate the power of communication, how we give things like news. You can give news in an empowering way or a disempowering way. You can, when you get given a chronic diagnosis, and I was diagnosed with breast cancer at 33, so I know what it's like to receive one of those. That that sense of empowerment, the sense of control that you thought you had, however illusory that might be, is ripped away from you. And so within that space, we have an opportunity to actually re-empower patients and actually get them re-engaged in their health and wellbeing. Or we have the opportunity to say, go home and rest, and I will take care of this for you. Now, I think all of us who are proactive individuals who want to do a little bit more would find that kind of situation really frustrating. And being repeatedly told by the healthcare system, no, we are going to sort it out. Nutrition doesn't matter, exercise doesn't matter, go home and rest, etc. It's utterly unproductive. And we really need to change that whole model. Because to me, if a person is engaged, yes, they might not have a medical degree, but like Rangan said, they do have an incredibly lived experience of what it's like to be them every day. They know their body, they know what works and what doesn't. They also can tell you what they're willing to do and not willing to do. And no matter what you tell them to do, if you're they're not willing to do it, it's utterly pointless, right? So to me, if you at the beginning, we start as a partnership, and we are also willing to acknowledge what we don't know, and what we all don't know is the whole medical and science community because there's a ton of unknown stuff. If we're willing to discuss risk-benefit openly with people, if we're willing to discuss what stage of change they might be in in terms of their lifestyle changes, and help them along the way, then I think we're going to transform the way healthcare is perceived.
Dr Rupy: Yeah, absolutely. You mentioned your diagnosis there at age 33. How has that changed the trajectory of your career? Was that the starting point for you looking at other modes of helping yourself and looking at medicine in a different way?
Dr Nina: It was more of a diversion is how I describe it. So medicine is actually my third degree, as you probably gathered from reading my bio. So I was a natural scientist first, then I trained in nutrition, then I went into medicine. And I have to say it was a really interesting experience entering medicine after you've done nutrition because you're like, what do you mean I only get two hours and it's all about calcium and vitamin D for bone health? How does that work? You're like, no, nobody else wants to know about anything. No, it's just thiamine for Wernicke-Korsakoff in alcoholics. Yes, that's it. That's the extent of nutrition. So then really what it, I have to say, breast cancer was really the thing that diverted me from a path of trying to fit a square peg in a round hole. As someone who was always interested in lifestyle and was actually practising nutrition alongside my medical training, when I was just working as a doctor in the NHS, I felt like I was leaving half my brain at home when I was going into work. And it was funny because on some of my wards, they're like, oh, here comes the vitamin D lady. I'm like, yes, but your vitamin, your patients are going to feel so much better. So to me, I did, I actually did an audit in one of our NHS trusts and we figured out that all of our elderly inpatients who were admitted for psychiatric treatment were 100% of them were vitamin D deficient, whether they were or not on Adcal-D3. And at that point, actually, we changed the protocol so that they were actually getting vitamin D replacement early on because of course, in inpatient psychiatric admissions is a long-term admission, people don't often get outside. So if they were deficient to start with, they're certainly going to be even more deficient when they come out. And of course, for that population, you know, bone health, immune health, all of those are really, really important aspects of life. But taking it back a little bit, really, I was, I was, you know, working all these crazy hours, you know, I had all these 12 days on, one day off shifts with a three and a half year old on my hands. And I was going, I'm not sure I'm really making a difference. I already had this niggling kind of dissatisfaction and, you know, really, I have to say, it really affected my mood and my mental health. And I was going, I was kind of thinking, this should be it. Like, this, I should be able to help people. And so my breast cancer diagnosis actually just took me out of this automatic bit of going, I'm going to stubbornly, because I'm very stubborn, going to stubbornly push myself into just continuing on that path. And I was going, but that makes no sense. And then as I was going through my own treatment, I because I was under incredible medical team at the Royal Marsden, all of my, you know, from my oncologist to my surgeon, they were all incredible people. But the kind of lifestyle information I could see on the wards and I could see in the chemo unit and I could see what was given people on the chemo unit, you know, have your biscuits, have a cream bun. This is the advice you get. Or go home and rest, which was my least favourite thing. I was thinking that just not lying with the evidence because as soon as I was diagnosed, of course, I hit the PubMed, as I usually would. And I was going, right, there must be more. And I realised there's actually tons of evidence within this space that we are not using in clinical practice. And that became very frustrating to me. And as I was putting in this in for myself, I could see how I was coping with treatment versus how women younger than me were actually coping with that treatment. They were on the floor. And so I could see an immediate difference between me and women who were just receiving conventional care, were not engaging in anything that was supporting them. And I remember this phase during the second three months of my chemo, I was sitting there with my oncology nurse, and she sort of sat down and looked at me with a cocktail and said, how are you? You know, and I was like, this was lovely because she was trying to be compassionate. I said, yeah, I ran a 5k yesterday and she nearly fell off the chair. And I was like, but that's, but that was me during that phase. The phase before that, those three months of EC, you know, actually I was quite fatigued, but I did yoga, I did walking, I looked after, ran around after my child. You know, that was appropriate for me then. During the taxane phase, I felt really well. Some people don't. But to me, the right thing to do was to move more. And my surgeon still jokes that I was with them for about five minutes because after an eight-hour op, I was discharged within 72 hours. But I pre-habbed. That's why I was out of the hospital within 72 hours. So to me, I have a lived experience of how using integrative approaches, and that means the best of conventional medicine and the best of everything else I could do for myself that my oncologist could not really advise me on, really leads to much better outcomes. And so when I came out of that, I went back into the NHS part-time as I was figuring out this kind of part-time and building up my integrative practice balance, and then eventually I said, no, okay, I'm going to do this because I think this is how I can deliver the most change. I think I can innovate hopefully from outside the NHS back and train NHS professionals. And I can also demonstrate it through research as well as clinical audit, what can be possible. And I think as we all know, some of the organisational structures within where we work can be really tricky. I mean, Professor Robert Thomas has done such an incredible trial where he was looking at substituting chemo room snacks from biscuits to nuts and healthy snacks and has shown significant improvement in metabolic parameters. But yet when the trial finished, all of this got withdrawn and you were back to normal. So the amount of inertia, as we we have to admit, there's an amount of inertia in the NHS that this is the way things are done and like we have to conform to this. And to me, I'm a scientist, right? I'm a scientist before I'm a doctor. And to me, I'm going to be curious. I'm going to ask why and I'm going to challenge the status quo because to me, this is not good enough.
Dr Rupy: Yeah, absolutely. And and I I I completely resonate with that. I mean, it's like wading through a treacle of bureaucracy working within the NHS. I definitely want to come back to some of the courses that you're doing to train practitioners outside of the NHS who are working in the NHS as well. Um, and I'm glad we started with the agency conversation about getting patients engaged as well as your personal story. Let's dive into some of these common hormonal dysfunctions that you treat, particularly with a focus on autoimmune disease. So how do you first approach somebody who comes into the clinic? How do you structure that consultation? And let's do a bit of a dive into some of the topics you're going to be talking about like thyroid disease.
Dr Nina: Sure. So when someone comes in to see me, I have the luxury of having lots of time with them, which is the luxury I have obviously in the private setting versus the NHS. But usually, they would have filled in some forms before the consultation. That's really important to me because actually, it allows the person the opportunity to self-reflect on what their maybe lifestyle habits were. So we do a three-day nutrition lifestyle diary. It also allows them to maybe think about some of the key events in their life because they have to do a history for me. And sometimes, even before they come to the consultation, they've had some aha moments just going through the paperwork process because they've gone, oh, so now I know why I have gut problems. I had a Giardia infection when I was a child. And then I had that norovirus. And then I was given those antibiotics for my acne. And then I was given lansoprazole because I got some reflux after those. And so people actually start making connections for themselves, which I think is that first step of engagement. And then they might also submit things like their consultant letters or their GP letters or any other test results, etc. So even before I come to the consultation, I usually would have spent up to an hour prepping for it. So I would have read through all the paperwork and I would have formulated a little bit about what I need to dig into during our conversation. And then the first thing we do is go through the person's timeline. We start with family history, we start with any genetics that they have any available, and we go all the way through up until now. And that journey is fascinating because it tells me the why. Why this person with this presentation and why now. And this is, I think, another major difference between science and medicine. So I did science and medicine both at the same university, and you'd think they're relatively similar trainings, but they're not. So with medicine, it was really interesting because we just ask what. What symptom, what disease, what treatment, right? We don't ask why. Nobody's interested in the why, funnily enough. We talk about risk factors at the beginning of our presentation, that's it. As a scientist, that's all you do every day. You ask why. Why this, why this, why this, why this? And that's what you're interested in finding out. So to me, that fundamental why tells you the how. If you know the why, you know how to actually shift that person's physiology. And again, the outcomes we see by using this approach are what is considered not possible in conventional medicine, but I can document this with NHS blood test results, actually, because many of my patients are under the care of NHS consultants as well as GPs. So really, we start with that timeline, and by the time we finish that timeline, we usually have a key idea of what some of those contributory factors might be. And that's why I use the functional medicine approach as a lens in a way, mainly just to look at those different systems and think about the ones that we might be wanting to target. So in autoimmune disease, there's a pervading theory that's developing at the moment that it is this cross-section between your genetics, in terms of genetic predisposition, your gut-immune axis, so that's increased intestinal permeability, dysbiosis, as well as that disrupting immune regulation, and your exposures. So any kind of environmental exposures that could be a trigger for that, for example, gut-immune axis to go off track. And that's very relevant for autoimmune thyroid disease. So once we kind of unpick that, we can say, okay, we think we know what might be going on, then we might direct either further testing or we might put in some upfront interventions, as well as optimising everything. So as a medical doctor, I will still do the medication review, allergy review, all the usual reviews, I'll do appropriate referrals for anything that might be red-flagged. And then we come up with a plan, and that's where the integrative medicine comes in, because that's my toolkit. And so I will still have all of my normal medications in my toolkit, but I will also have nutrition, lifestyle, psychological and emotional wellbeing, you know, in terms of anything from referrals for trauma therapy to mind-body medicine, as well as evidence-informed complementary therapies, anything from acupuncture to yoga therapy, etc. And so we then make a personalised plan based on what, based on the why, gives me the how, effectively. And that how is then expressed through an integrative medicine plan. So people will then get a written plan, usually some recipes to go with it, quite often that's where your books come in. Podcasts, things to listen to, things to read about, because to me, when I work with someone, at the end of that process, I want to, my happiest day is discharging people from the clinic, because to me, not only are they better by that point, but they have learned important skills and information to be able to self-manage their health and wellbeing going forward. They know their own SOSs to use when they're starting to go off track, and they also know when they've exceeded their own capacity to self-regulate at that point, and they need to seek further help. So to me, that empowered person that walks out of that room is why I do what I do, because that's, that's, that's what we get into healthcare for, right? That's why we work so hard.
Dr Rupy: Absolutely. And on the subject of empowerment, I think the first bit of the consultation that doesn't actually involve the patient directly in a room, I think is really telling. And a lot of people listening to this who might not have access to or the funds or the ability to afford a private consultation can do this exercise themselves, right? A three-day nutritional assessment or just a collection of food diary, a timeline of when they last felt amazing or last felt well. You know, I don't think we talk about these things because when you actually put that on paper, it encourages reflection, encourages interception, and it gives you a a more a clearer idea of when things might have started going wrong for you as well. And I think, you know, that that as a start, I mean, I imagine a lot of what you actually diagnose or pull out as something that you can work on comes from that part of the consultation, right?
Dr Nina: Absolutely. There's absolutely no reason why we can't do it. And for people with autoimmune disease, Dr Jenna Macciochi just written a lovely book, of course, in terms of looking at personalising your immunity in terms of blueprint. And she talks about the timeline within that. So you can absolutely get a book like this, you can download nutrition lifestyle diary. I mean, Dr Diana Minich has amazing stuff on her website in terms of food and mood diary as well as looking at kind of looking at monitoring your colourful foods. All of these resources, this particular bit is freely available. So you can absolutely go off and do it and do a bit of self-monitoring and encourage yourself. I do think that when we reach that real complexity of someone really, really ill, that's when you need expert guidance. But if we do lifestyle medicine really well in the NHS, if we start with that, I wouldn't see half the patients I see right now. And that's really the aim of the game. Precision health, to me, comes in at the complex end of the spectrum. Do lifestyle medicine really well. Look at some of your drivers of dysfunction. Look at everything from psycho-emotional wellbeing. Do that diary. Think about your early life traumas. Think about intergenerational traumas. Thinking about what your emotional history and attachment style has been. All of this will actually play into your health and wellbeing. That is something you can do something about yourself. However, when we look at kind of more like multimodal medications, people getting out of control with their autoimmune disease, when they're actually ending up in hospital, when they're at risk of, say, for example, losing their bowel in IBD, or when things are flaring out of control, that's where precision health comes in, right? That's actually that's where you want to do. And if we do precision health well, to me, one of my frustrations that I have now that I'm in private care of working with the NHS is that I can't. But actually, if the NHS could slightly open their mind and think, if we refer some complex cases for collaborative management with a CQC registered precision health and integrative medicine clinic and give them six months to work on this patient and we monitor the outcomes, it could be transformative because we take patients who've been in hospitals usually for an admission, I don't know, six to eight weeks sometimes, you know, think about how much that costs the NHS. And I take them at that point, they might have had two or three admissions a year like that. And they go to having maybe one acute admission every couple of years for whatever it is that's happened outside of their usual. That's a massive saving of money. So I think we need to think about it and I love collaborative care. I collaborate with a lot of because I'm private care, I collaborate with a lot of private consultants, for example, private GPs. And we see those synergies and we see transformative stuff. We see things like the case I presented yesterday, you know, where we took someone with three autoimmune diseases who was on their best control was out of control, frankly. And we actually reduced their immunosuppressive medication and got all three diseases under remission. With no change in medical management otherwise, other than a reduction in immunosuppressive medication. And I have this documented by the NHS. No fancy tests, nothing weird and wonderful, but that's through doing consistent personalised work, looking at the gut-immune axis, looking at the drivers. But then this person isn't going to stay with me forever, nor would I want them to. You know, once we get them into a good state, that's that's when they continue with all of their good lifestyle habits, with all of their other work to be able to maintain that health and wellbeing. And as we know, autoimmune disease, it's not an easy thing. It's not like, oh, we got you in remission, hey presto, you're going to stay there. We do need to be careful and there are environmental triggers that can come at us later in life, you know, when we're in remission that can might throw us off course. But if we have empowered the person, if they know how to deal with it, if we've built up enough resilience, that's a wobble. That's not off the cliff.
Dr Rupy: Yeah, absolutely. And even within, you know, conventional care of an autoimmune condition, you're going to have waves of flares and and where you have better months and and not so good months. So I think compared to the standard that we have already, if you integrate lifestyle medicine into that as well, it's always going to have a better outcome if you can, you know, empower them to do those things. I wanted to dive, now that we understand the general sort of premise of a lifestyle medicine consultation and how you might approach someone within precision medicine, why don't we dive into a common topic that we haven't really talked about too much on the podcast as it is quite complicated, an example of hypothyroidism. Commonly women who have this issue. How would you go about trying to approach this particular patient? I'm sure you've got loads of case studies with, you know, the various reasons as to why someone might have this as well.
Dr Nina: So the most common cause for hypothyroidism in here in the UK, because we're a developed country, is Hashimoto's thyroiditis or autoimmune thyroiditis. And that can have two phases. So most often we think about hypothyroidism as of course the final phase and that's the chronic phase, but you can actually have that acute phase where you get hyperthyroidism, which a lot of people aren't aware of, actually. And then that will, so that's that initial destruction of the thyroid gland will release a lot of the thyroid hormone into circulation. So people actually get hyperthyroid, get all the palpitations and the sweating and the tremors, etc. And then as that destruction proceeds, they will go into the hypothyroid state. And that's quite often where we look at it. And in the hyperthyroid state, when they go actually high, there's a little bit of confusion about what we can diagnose here because there's an overlap between Graves' disease and Hashimoto's at that point. It's quite tricky to sometimes differentiate that. But when we land into hypothyroidism, when we're looking at Hashimoto's disease as an example, again, I assess that that triad. So I look at the family history. And so your risk of Hashimoto's thyroiditis can be increased by a personal history or family history, but also in terms of overall picture, it can be increased by celiac disease, type one diabetes. The other features of your whole health timeline can also play into it. So if we're having someone with recurrent miscarriages for whom no other cause has been found, we really, really need to look at the thyroid. Quite often fertility clinics are really good at doing that. But so we look at personal history of any other autoimmune conditions, we look at family history of all the typical autoimmune bundle effectively. We will look at the gut-immune axis disruptions. So this is looking for me, if someone has a history of antibiotic use from childhood, and one of the key things I would love to encourage people to do, if they're asking about antibiotic history, is ask a slightly funny question about it. If you ask a person, did you take antibiotics in your childhood? The likelihood is they go, I don't know, I'll have to ask my mother. But if you say, have you had banana-flavoured amoxicillin? They might say, oh yeah, I remember having banana-flavoured medicine shoved down me. And actually quite often, I think that's ingrained in so many people's heads, that banana, yellow, disgusting coloured. Exactly. And actually, this is what, this is what, so I sometimes ask because if you ask people, they won't remember, but if you remember that key trigger point for children, that disgusting emotional trigger is very well embedded. Actually, people will say that and people will talk about maybe, maybe I was a colicky baby, maybe I was having a lot of ear infections, I was given the banana-flavoured medicine for, maybe I had acne and I was given antibiotics for that. Maybe I had chronic UTIs and that was another thing that comes up in women's 20s, for example. And so we build up a picture of kind of how disrupted their gut microbiome is. And occasionally I will use a stool test. It's not appropriate for everybody, but occasionally if I really need to know what's down there, and acknowledging that's only a snapshot in time and with that limitation, it can be quite useful. We'll look at the immune system, so we will look at people's, you know, simple full blood counts, look at neutrophil lymphocyte ratio, we'll look at their inflammatory markers. We will look at thyroid autoantibody levels as well as the overall thyroid profile. And then we'll look at any other exposures. So sometimes people will come with weird and wonderful things like maybe excessive bromine exposure or maybe there's a heavy metal exposures in their lives that we actually don't think about. And occupational history is really, really important here. And then based on what the individual triggers are, that's how we work. And there are some more general things that we do with people. So overall, the baseline really should be what you talk about all the time, the whole food-based anti-inflammatory diet. And while we don't have strong interventional studies in this area, we do have association studies that suggest some of the risk factors for Hashimoto's in terms of, you know, increased intake of processed meat, red meat and animal protein, with the protective factors being fruit and vegetables and Mediterranean diet traits. So that's kind of a no-brainer because it's also protect them in terms of their cardiovascular risk. And quite often, women just don't get talked about in this setting. You know, a man comes into A&E with the whole chest pain, oh, here we go, heart attack. A woman comes in, oh, you've got reflux, love. And I'm like, no, okay, we've got to get away from this. And we know the stats, don't we, Rupy, that actually so many MIs get missed in women.
Dr Rupy: 100%. Actually, the British Heart Foundation are doing a bit more of an awareness campaign around this because it's a bit of a misnomer, a bit of a myth that women are less likely to have cardiovascular problems, but as we know.
Dr Nina: And of course, perimenopause, postmenopause, we are having that's where the risk really climbs. And that's also where quite often the first presentation of something like Hashimoto's thyroiditis might present. And so even if you're thinking a woman is perimenopausal, don't cast a tiny net. You really need to exclude other causes. And anybody with Hashimoto's thyroiditis, particularly if they have slightly uncontrolled hypothyroidism, will be in an increased cardiovascular risk. So having that kind of baseline of a whole food-based Mediterranean style anti-inflammatory diet is going to protect them from multiple angles. And I'm a big fan of, you know, one stone, several birds kind of thing. If I'm going to ask you to do something, it'd better have multiple effects on your physiology, thank you very much. I'm not going to give you 20 different things to do, that would be ridiculous. But then we will look at, of course, movement, we will look at psycho-emotional wellbeing. That's really important because trauma is an important thing that will change your whole immune regulation overall. And of course, cortisol, because another thing we've got to think about is the thyroid axis, the HPT axis doesn't sit in isolation. For women, it will interact with their gonadal axis, with their sex hormones, it can affect their periods. And it will affect other things like their bone health. For other side of things, their adrenal axis, the cortisol fluctuations will affect the way that the whole HPT axis functions. So it can decrease things like normal TSH production up there, but it will also affect the T4, the slightly more inactive thyroid hormone to the active T3 conversion. So if we are missing that part of the picture, we're not doing our patients a really good job of helping them. And then the other side of it is, so if I'm looking at the gut specifically, then I might do some specific interventions targeted at that. And we usually use programs that are looking at specific interventions. But there's some general things we can do as well. So two interventions I talked about at this conference were selenium and myo-inositol and black cumin seed. And again, they're very simple interventions. They don't have any, they have a really favourable risk-benefit ratio. So for example, people were given two grams of powdered black cumin seed, which is quite easy from my perspective to get. And actually it's been used extensively in Asian cooking. We just don't know it in the UK, do we? And just by giving that, you can actually improve people's cardiovascular, cardiometabolic profile quite significantly, as well as decreasing their TSH and thyroid hormone levels and their antibodies decreased. Like that's a simple intervention. Eating two grams of powdered black cumin seed, you know, put it in your curry, put it in your soup, put it in your salad dressing. That's something that someone can do that has minimal interaction with anything else they're on, frankly, and can potentially improve their thyroid function. And selenium myo-inositol, there have been a number of studies within that setting, looking at both kind of overt hypothyroidism as well as subclinical. And here we see that using doses of 600 milligrams of myo-inositol with 83 micrograms of selenium, given as selenomethionine, either once or twice daily, could significantly improve people's thyroid function as well as decreasing antibodies by up to half. Which is not something we look at in GP land, as we know, or in hospital land, because to be honest, we don't measure thyroid antibodies. So don't ask, mainly because we can't do anything about them with conventional medicine. What are we going to be able to offer them? We just, here's your levothyroxine, I'm going to monitor your TSH and your free T4, that's it. Because we can't offer anything in conventional medicine, for us, it doesn't make sense in the NHS to monitor thyroid antibody levels. But for me, because I'm trying to unplug the autoimmune process at its core, I need to do it. And I do there's acceptable fluctuations within that. But when you have someone going from 300 down to 100, down to 90, that's a significantly measurable change. And we're about to publish some data on that, actually. But looking at this, again, this is something that's, you know, from the supplementation perspective, it's relatively safe. I wouldn't exceed more than significant amount of selenium. So 83 micrograms twice daily is kind of maximum of what I would do because selenium long-term can bioaccumulate and cause toxicity. So we don't overdo it. Like anything in our body, right, we love the Goldilocks zone, right? Not too little, not too much, just right. And same goes for nutrients, like anything from vitamin D to selenium, we have to be careful with those things. And of course, we optimise other factors. So looking at their omega-3, looking at their vitamin D, of course, there's been that VITAL trial which shows an amazing reduction in risk of autoimmune disease in high-risk populations with 2,000 IUs of vitamin D daily. And omega, exactly, very accessible. And also with the omega-3, to be honest, that was added to the trial. I didn't think they used high enough dose for that, which is why I probably seen a smaller signal from that. But it'd be interesting to see if they used adequate levels of 1.5 gram minimum of EPA and DHA, whether we would actually see an even stronger effect with a combined group. So those are the things that I kind of do, I guess, more generically overall for people.
Dr Rupy: I love how you said this is generic, by the way, because in my mind, when most conventional doctors talk about hypothyroidism or they think about a patient coming in with hypothyroidism, low levels, we'll check your TSH, we'll give you some levothyroxine, we'll see you in the next couple of months to see what your levels are to make sure that we've got the right amounts. There is no consideration to any of the things that you've just been talking about, the sort of genetic components, the gut components, the inflammation components, the stress components, all these different considerations. And you're describing that as generic, which is really interesting to hear.
Dr Nina: I guess I was referring more to the black cumin seed and the myo-inositol and selenium, but yes. But you're right. I think to me, to me, I guess this is, this is baseline. Actually, this is enough for a vast majority of people. And the other thing we need to be aware of, and actually that's something we can do as doctors in our GP practices or in hospital practice, that we must assess the other nutrients that are involved. Because quite often, we will come to us, say, for example, we'll give them levothyroxine, we'll see them later. Nobody's checked their vitamin D levels, nobody's checked their iron levels. Now we do know that iron is foundational for women. So many women are iron deficient, as well as we're looking at obviously, we're not going to check necessarily zinc and selenium, but that's something that's also really, really important within the thyroid axis, making sure that people are actually eating some of those minerals. And as we know, the intake of some of these can be very low in our population. So, you know, if anything that you can do is just to make sure that your next Hashimoto's patient comes through, you actually measure and optimise their vitamin D, you measure and optimise their iron, ideally through food instead of giving them ferrous sulphate, which gives them horrific constipation, which they won't thank you for, as well as black stools, which is delightful. So I think food, let's do food, as well as looking at, you know, if they're not nut allergic, two Brazil nuts a day is enough to cover your selenium status. Talk about, you know, zinc, you can talk about seafood, you can talk about pumpkin seeds. There's certain food sources we can incorporate quite easily within our life to really optimise the nutritional support that we need for that person. And then, you know, if they are willing to try some black cumin seed ground in whatever form they like, maybe you should make a recipe out of it. That would be good. It could be my my favourite Hashimoto's recipe. That's a challenge for you.
Dr Rupy: I'll have to think about that. Yeah, yeah. We are creating a selection of new recipes actually for the app that we just launched. We haven't got a specific health goal directed at thyroid health or even women's health actually, which I definitely need to work on. But I will definitely bear that in mind. And I'll have to look at some of those studies as well to look at the potential mechanistic reasons as to why that would be improving some of those antibodies.
Dr Nina: What's interesting because I mean, inositol is quite in a way, I guess an easier mechanism because it's very well studied. And that's actually affects how TSH is secreted, as well as affecting the hydrogen peroxide production with how we make our thyroid hormone, how we make our T3 and T4 in the thyrocytes. So there's some very easy, for so myo-inositol is a pretty easy mechanism. It's actually part of those signalling pathways that will result in better TSH control, will result in better thyroglobulin iodination effectively. So that's quite easy. Selenium, again, is a multiple effect. It's got this whole cascade of effects. It's a key factor in multiple selenoproteins from your GPX, your glutathione peroxidase, which is an important regulator of oxidative stress within all our cells, but particularly important in those thyrocytes because those cells that make our thyroid hormones, they have to go through a lot of oxidative stress because they're creating very reactive iodine species that you have to then attach to a protein to make them safe. So antioxidant balance is actually really, really important from that perspective, as well as our simple T4 to T3 conversions. Those deiodinases that do that job, they're selenoproteins. So to have an adequate levels of selenium will impair your production at that level, at the level of actually making T4 and T3, as well as your conversion into the active hormone. So I think we kind of understand that mechanism better than we do the black cumin seed, which we might speculate that might have something to do with thymoquinone and some of the fact that it's an antioxidant and anti-inflammatory, but I do think we need to do more mechanistic studies to figure that bit out. And thymoquinone is just a fascinating thing that we could talk about another time.
Dr Rupy: Yeah, yeah, absolutely. And I think as you're you're describing some of those mechanisms and the processes, a lot of that is going to go over the head of our listeners, including myself, if I can't, I'm very visual. I have to look at the actual pathway to actually make sense of it.
Dr Nina: We'll make a diagram.
Dr Rupy: We'll draw a diagram. We'll make sure we put some of that in the show notes. But this brings me on quite nicely actually to the fact that you're teaching other practitioners, other clinicians of various disciplines, how to think about and approach patients with these quite complex issues, utilising all the the suite of tools that you have available to you, both in the NHS and outside of the NHS as well. Talk us a bit about the courses that you're you're running.
Dr Nina: Sure. So I have two main directions. So one of them is focused very much on women's health and it's called the Hormone Gateway course and it's it's basically both nutrition and medical professionals that normally come to that who are interested in just looking a little bit broader, looking at the evidence around things, anything from looking at, you know, trauma, looking at the thyroid axis and common autoimmune diseases to looking at some of the typical sex hormone related dysfunctions from PCOS to endometriosis to PMS, etc. So there isn't a massive focus on fertility specifically because there are other courses that run along that, but hopefully it's a good foundational tool to manage those three axes. And then my second bit is integrative oncology and I'm the co-chair for the British Society for Integrative Oncology with my amazing colleague, Dr Penny Kehayoglou. And this is not something I run for them, but we are hoping, again, we're really hoping that we're going to get a postgraduate qualification in integrative cancer care at some point in the next couple of years. So that's something that we're actively working on as BSIO. And that's going to be a separate initiative. Privately at the moment, what I do is a systems approach to cancer. So very much talking into the hallmarks of cancer as well as this whole systems, whole person approach, really starting with the foundation of human resilience within that whole process, to be honest. Because sometimes we get so mechanistic down, you know, in oncology, right, block that pathway, find that drug, that target. I'm like, I don't care how targeted your drug is. If your patient's sick, too sick to take it, you're never going to get the outcome. So to me, integrative oncology, which again is this beautiful, rational synthesis of the best, most targeted conventional cancer medicines that we've got, you know, from chemotherapy, surgery, targeted drugs, immunotherapy, etc. combined with nutrition, lifestyle, psycho-emotional wellbeing and resilience building for people, as well as complementary therapies, that synergistic approach transforms people's lives. So that's what we want to be able to teach across the board. We need to unite the NHS, private and charity sectors behind this as a goal. Because as we know, cancer targets are gone, God knows where we went la la. People have been suffering horribly through both the COVID pandemic as well as the consequences of this. And we need to again, put some good resources in people's hands and both the practitioners' hands, and I mean the whole multidisciplinary team, not just the doctors, because it's not all about the doctors. We love doctors. But, you know, the clinical nurse specialist, the OTs, the physios, the radiographers, all of us have a role to play in that person's journey through healthcare. So let's empower people to be able to deliver simple interventions appropriate to their scope of practice to be able to support someone through it.
Dr Rupy: Yeah, yeah. I I've got up in front of me the schematic, the diagram that you've you've added to one of the blog posts, I think you put on the website there. I'll make sure that we put that and link to that in the show notes because I think it gives a beautiful, well-rounded overview of how an integrative oncology consultation would work. And it makes so much sense. And there's nothing particularly left field included there, but the only thing I think that people might be irked by is the herb and supplement additions, right? And certainly that's a lot of pushback. I would imagine a traditional oncologist might have. How how do you sort of manage those conversations with your sort of bonafide oncologists that might be saying, well, there's not enough evidence for this and you could actually be reducing the efficacy of chemotherapy and all the other therapies that they have.
Dr Nina: Well, very fortunate that during my degree, I did pharmacology. This is the benefit of being a natural scientist. You do your pharmacology. So you know all about various, you know about the sip system, you know about the phase one, phase two detox, you know about the various transporters and pumps and the AC50s. But that gives me a very different, I think, conversation that some maybe sometimes some nutrition professionals would struggle with having that conversation. Because number one, we are incredibly careful about drug-nutrient interactions or drug-supplement interactions in the clinic. So we will usually look at least two sources to check those. So we'll look at Natural Medicines Database, which is kind of the standard in the industry. We will also normally check PubMed for the most recent interactions. So for example, give you an example of that. About three years ago, the tamoxifen and curcumin interaction wasn't yet showing up on Natural Medicines Database. Yet when you go to PubMed, you can see an in vivo study in women with tamoxifen showing that really high dose curcumin, I mean, pushing it to something like two, 3.2 grams per day as supplemental, right? And that's high dose curcumin extract, not turmeric. So giving them something about, I think that's either 3.2 or 4.2 off the top of my head, but really high dose curcumin extracts was reducing the levels of endoxifen, which is the active drug that tamoxifen gets converted to. And therefore, there was a caution around do not use high dose curcumin extracts. Now, does that mean you can't eat turmeric in your curry? No, it doesn't, because we haven't taken the whole population of India off or anywhere else that has curry as a normal food. We haven't taken them off just because they go on tamoxifen. So nutrition is different. And sometimes there's a lot of misconceptions, certainly even in very well-educated circles about what's clinically relevant, right? What is an in vitro study that shows a potential theoretical thing, and then we have to evaluate risk-benefit ratio for, and that what is a truly meaningful clinical interaction. And that's within that scope is where we have a discussion. And you know what, the patient has to be involved too. Because it's not actually, as much as we like to think the doctor's decision what they do and don't do, because I'm sure they've told your patient not to do stuff and they've gone ahead and done it anyway. So to me, saying no and ending the conversation, guess what, it's never actually going to happen. There's a good proportion of people go ahead and do something anyway and do it without safety. So let's have an open discussion. Let's actually have a discussion rather than unilateral decision making. And let's talk about it. And I will never recommend in my plans something that has a clinically significant interaction with a good evidence level of B and above, right? But if someone has an in vitro potential interaction of level evidence D, and I think that's going to help improve their various immunological parameters or something else, that's a very different level. So again, we need to understand about, like we would evaluate in any other medical setting, what's clinically relevant. And we're not afraid of polypharmacy, right?
Dr Rupy: No, of course. That's what I was going to be my next point. The the polypharmacy that we're happy to cope with is is pretty astounding. So, you know, the addition of a herb or a supplement, as long as you're and you're being rigorous about it as well, it stands to reason. And particularly if you're personalising it for that individual as well, it stands to reason that they are good additions and that they can have some efficacy as well.
Dr Nina: And you monitor, you know, ultimately to me, we do extensive monitoring at the clinic, you know, we will look at everybody's oncology bloods, we will run some additional bloods quite often that don't get done. We will look at people's inflammatory markers. So that I can see if I've put in, so for example, having high inflammatory markers and a high neutrophil to lymphocyte ratios can actually decrease the response to immunotherapy in some patients, as well as their gut health having a role, of course, which is a whole other conversation. But if we're looking at that, this is something we can't do anything about in conventional medicine. We can't pre-hab people for immunotherapy right now. Expensive drugs, lots of side effects, yet we can't pre-hab people. So we're thinking, but if I can optimise a person's NLR, using some of the anti-inflammatory interventions, which for which the scope lies from nutrition to some targeted supplementation that doesn't interact with their medication, I can monitor it. I can tell you whether I'm effective or not. And that's what I do. I mean, as a scientist, I have to document what I do. It would send no no reason why I wouldn't. And I will see what's effective. And you know, maybe some things are more effective than other people. And actually that's what we need to study in the future. We need to think about how do we combine integrative oncology interventions in the most safe and effective way so that we're not saying no and we're not saying yes. Because the other thing is like it's not no to everyone and it's not yes to everyone. Not everybody needs tons of supplements, funnily enough. But let's sit in the middle like we do with everything else and say it depends. It depends on you, it depends on your nutrition, on your on your tumour, on your condition, on what else you are doing in your life. So let's be smart about it.
Dr Rupy: Absolutely. I I I feel like we're we're just warming up, but we're going to have to call it there. But I I I I would love to do another session with you and deep dive into specific topics. We haven't really spent that much time on the exposome. I'd love to talk a bit about certain herbs and supplement regimes that you're a fan of. But for now, I I I think we'd love to promote your your course for for clinicians and and try and get more people because we need more clinicians like you. You're amazing. So thank you so much for your work. It's brilliant.
Dr Nina: And thank you for your work. You're amazing too. It's great to see the community of us building to change the paradigm.
Dr Rupy: Yeah, I just play with vegetables. Which is a very important job. It is. Yeah, yeah. I like veggies. Brilliant. Thank you so much. That was wonderful. Thank you so much for listening to this week's podcast with Dr Nina. Remember, all the information and more is on the doctors.kitchen.com website where you can also sign up for our newsletter, Eat, Listen, Read, where every week I send you a recipe, something to listen to, something to read, something to watch, as well as a funny joke at the bottom as well that people love. I will see you here next time.
