Dr Rupy: I want to dive right into this. At the start of your book, you describe PCOS as an epidemic. And I was actually quite shocked to see that in an economic meta-analysis in 2021, PCOS accounts for 8 billion dollars in healthcare costs annually in the US alone. Why does it cost this much and how come I wasn't aware of this?
Dr Nitu Bajekal: That's a great question, Rupy. Actually, most people aren't aware of this, including doctors and health professionals. And that's because three-quarters of people with PCOS never get a diagnosis, first of all. But when they do, the effects, the short-term, medium-term and longer-term effects cost the economy because half the women with polycystic ovary syndrome by the age of 40 will have type two diabetes if they're carrying excess weight. Gestational diabetes is a real problem, that is pregnancy in diabetes, or pregnancy, diabetes in pregnancy, as well as later on, you know, womb cancer, type two diabetes, increased risk of heart disease. All these things add up. So although they may not have had a diagnosis of polycystic ovary syndrome, the results of having the condition end up costing the economy. So we're not doing prevention, we are sort of firefighting afterwards, rather than, you know, moving in much earlier. One in 10 women are actually affected by the condition, polycystic ovary syndrome, but in certain subgroups, the Asian population, that is so sadly not been researched properly at all, those who are from other ethnic minorities, groups, Hispanics, African Americans, they all have a higher incidence of polycystic ovary syndrome. Those who are struggling to conceive, those who are carrying excess weight, the incidence can be as high as one in four. That is not just an epidemic, I would say it's a pandemic, but nobody is talking about it. And that's why one of the reasons we wrote the book, you know. So we wanted to reach people who either didn't know they had the condition, or if they did, they had nobody had joined the dots and they were being either dismissed by their health professionals to come back. I have see so many patients being told, come back when you want to get pregnant when they have missing periods or irregular periods. And so these are the things that I we felt, you know, I wrote it with my daughter because I actually started writing a general book. I had been wanting to write a book for years and never got round to it with my busy lifestyle and my job and career and managing a family. And when I finally got down to writing it, I started writing a general book and Rohini, my daughter, who's a co-author, said, "Mum, why are you writing a book that has got two pages on PCOS, two pages on endometriosis, another few pages on menopause when you are, you have 35 years of experience and you are special, specialise in all these areas?" And she herself has PCOS and it took a long time to diagnose despite being the daughter of an OBGYN. And so we wanted to write the book that she wished everybody else could have because she obviously had me to help her. So that's how the book came about.
Dr Rupy: Yeah, yeah. I it's amazing. I I met your daughter briefly at a Romy Gill's book launch a couple of months, maybe it was a year ago now. Time flies post-pandemic. Yeah, yeah. And she's so lovely and you can tell it really comes across in how she's shared her story so bravely in the book and we'll get to your sort of your own story as well. But, I think it's a it's a lovely combination of the mother-daughter and having that book that she wished that she had. Let let's dive into some of the the elements that are driving this disorder because the the prevalence, the increase in prevalence, particularly amongst ethnic minorities, I think is seen across lots of different conditions that we see, some of which are related to PCOS. What's driving this condition and I'm assuming it's going to be a genetic component as well, which is explaining this. But what give us a sort of a summary, a sort of a bird's eye picture of what we know about what is driving PCOS.
Dr Nitu Bajekal: I think I'll start off, Rupy, just by explaining what the condition is, because there may be listeners who may not actually know what PCOS is, which is polycystic ovary syndrome. It's the most common hormonal condition to affect women worldwide. And when I use the word women, I do want to stress that it's anybody who has female reproductive organs or has been assigned female at birth, because that is important, however you may choose to identify later. And it affects, as I said, one in 10 women officially, but we think in certain subgroups is one in four. So it's the most common endocrine condition, and I want your listeners to think of it as a cousin of type two diabetes. And so, once you understand that, it's a complex condition, it's a genetically driven condition. So you will have family members often, if you take a good enough history of a mother or a sister, because that increases your risk, and epigenetics and genetics comes in because it also works on the way the insulin receptor is modulated and things like that. But interestingly, there was a wonderful study of 172,000 men, I think, in an Oxford study, which said that men also show the characteristics of polycystic ovary syndrome. Now, that is something that is really interesting. And what do we mean by that? So PCOS is a hormonal condition, but it doesn't actually, the ovaries are not diseased, it affects the function of the ovaries. So it is an endocrine condition. It is managed a lot by gynaecologists, but really it's an endocrinologist who should be managing this condition. And men have symptoms like metabolic syndrome, they have raised triglycerides, increased waist size, they have early frontal loss of hair or frontal balding as we say, type two diabetes, increased risk of heart disease. So if you're a man listening and you have a mother or a sister with PCOS, you need to also take that extra care because you also may have those symptoms of PCOS, because PCOS is mistakenly named polycystic ovary syndrome. There are no cysts in the ovaries. What those are are immature egg follicles that you're born with, and every month, one of them is supposed to race to the top and, you know, release its egg, which is called ovulation, and that gets disordered because of the signals coming from the brain and from insulin resistance, which is tends to be the main driver. So your question was, what is actually driving this condition? About three-quarters of people with PCOS have a background of insulin resistance. Eight out of 10 women with PCOS actually carry excess weight, but 20% don't, and even some of them will have insulin resistance. And insulin resistance, for your listeners, is basically a condition, a situation where your cells in all your body, whether it's your muscle, whether it is everywhere, every single cell in your body becomes resistant to the action of insulin. So the insulin is a hormone. Hormones are chemical messengers. They are basically released in a certain organ, say for example, the pituitary gland in the brain releases hormones like FSH and LH, or the pancreas release insulin, and they exert their action in a distant organ. That's what a hormone is. It's a chemical messenger. So when your body or the cell is clogged, either for example with fat, or the insulin receptor gene is causing a defect in the receptor, which is where the insulin hormone will attach itself, what happens is the cell says, no, no, I don't want you to come in and move the glucose in. So what happens is the body then sends a message to the pancreas saying, produce more insulin, not actually getting the message. So the insulin levels rise, and as insulin levels rise, what happens is there is another hormone called insulin-like growth factor, which directly stimulates the ovaries to produce more androgens. Testosterone is what you would have heard of. And so that then results in many of the signs and symptoms of PCOS. So insulin resistance, when we treat it, however, and we'll come to that, we think that is one of the main drivers, but it's not the only driver. But it has to be in the background of genetics. So, you know, I want people to realise that it is a genetic condition that is hugely influenced by the environment, by the lifestyle. And it's not just what you eat or it's also, you know, the pollutants in the atmosphere, in what you're eating from. All these things are equally important. Otherwise, I find people tend to blame themselves, you know, oh, it's a lifestyle condition, so it must be that I have done something wrong. And that is a big problem because if you don't start talking to yourself with compassion, you're going to go down this rabbit hole of it's my fault and, you know, historically women have always been in that, made to be smaller than themselves, you know, immigrant women especially in this country. So, and women all over. So I I just think it's important to understand not to spend time blaming yourself. Speak to yourself as if you would to a loved one. So I I want people to understand that lifestyle doesn't mean it's only what you are actually doing. Yes, there are things that you can do.
Dr Rupy: I want to go back slightly actually to the PCOS because I think that's going to be pretty surprising for a lot of people that there aren't cysts in the ovary, right? And that this is actually a hormonal driven issue. This is an endocrine problem that is commonly managed by OBGYN as you just mentioned. How did we get to the the situation where we describe it in the in the description of the of the condition as polycystic ovary syndrome? What how do we get to this point? And and what maybe we should be renaming it? I'm not sure about your thoughts on that.
Dr Nitu Bajekal: So there was a big move to rename it as reproductive metabolic syndrome, but it's only just started getting airtime, PCOS. So I think it was then decided, leave the name alone. And the name really comes from, Rupy, when you look at one of the criteria for diagnosing PCOS. So in an adult woman, you need to have two out of the three criteria to be met if you're going to diagnose somebody with polycystic ovary syndrome. PCOS is a diagnosis of exclusion, which means that when a patient comes to see me, I have to be very careful giving before I give them a diagnosis of PCOS, because there are other conditions that can mimic it. And so you have to rule out things like ovarian tumours, adrenal tumours, you have to rule out hypothalamic amenorrhea, especially in a lean PCOS person, because it may be from over-exercising or from, you know, an eating disorder and other conditions. So it's really important, Cushing's syndrome or non-congenital adrenal hyperplasia. There are many, many conditions. So a really a good endocrinologist and a good OBGYN will not just label somebody because misdiagnosis can also be harmful. You don't want to overdiagnose the condition. And so what happens is you need to fulfil these three criteria. And what are these three criteria? The first one is one that most people would have heard of is missing periods or irregular periods. Now, a normal period should be between 24 and 35 days. Your period should be coming 24, 25, 26 days, 27 days, or 30, 31, 35. It shouldn't swing wildly. You shouldn't be missing periods. And if you're missing periods, especially for more than three months, or your cycles are 40 days, 45 days, that's not normal. That's not the normal signal that is going through your body. So that is known as anovulation. Your ovary is not releasing the egg every month. And so that is resulting in these delayed periods or missing periods. That's the first criteria. That's a clinical criteria. I just need to ask the patient, tell me your menstrual cycle. And every woman should be tracking her menstrual cycle from the time she starts her periods till the time she finishes. Then the second criteria. So the first one is not releasing the egg and period issues. The second one is signs of androgen excess, which basically means that you would have heard, and this is something that really saddens me a lot because people use the word testosterone as a male hormone. Women in the reproductive age produce four times as much testosterone as oestrogen. Most doctors don't know that. And so testosterone is as much a female hormone as a male hormone. And it depends upon your age, your gender, your stage of life that the testosterone levels fluctuate. But so the most famous of all the androgens is testosterone. There are others. And what happens is there can be signs of androgen excess, which is a second criteria. And how would you notice it clinically? Women may notice that they have adult acne, acne on their chin, backne, on their chest, they may have hair where they don't want it, on their chin, on their chest, they may notice scalp hair loss. So these are the critical signs. And so you can have both these, the first criteria of missed periods and acne, that may be enough to give you a diagnosis of PCOS, but you have to complete the whole circle. So you would do certain lab tests which will look at testosterone levels, the amount of free testosterone that is going around that is not attached to a protein by the liver. So there are certain lab tests that we also do that could be part of the second criteria. And then the third one is where the name came from, is an ultrasound. Now, a pelvic ultrasound, and you should have a vaginal ultrasound only if you've never been, never had penetrative intercourse. It should never be done in somebody who has never had vaginal intercourse or, you know, and so what is important to know about the ultrasound, you can do it abdominally as well in young girls. You want to look at the ovaries and there are, there's a particular pattern. There are these little empty, immature egg follicles that haven't matured, arranged in a pearl necklace or a rosary appearance. And so they appear like these little fluid-filled cysts, but they're really empty, immature egg follicles. And so that is the name where polycystic ovary came from. And also the volume is increased. Now, we don't use ultrasound or polycystic ovaries in teenagers. So you're not allowed to use ultrasound as one of the criteria. You have to use the first two. Why? Because adolescents actually have multicystic ovaries naturally and normally, and so you might get confused. So that's where the misnomer of polycystic ovary came from. Similar thing is people often say, I have pain with PCOS. Pain is not really a feature of those cysts. They don't grow to any size. They're not big ovarian cysts or things like that. So if you are having pain and you're listening to this and you've been diagnosed with PCOS, that is not normal. Painful periods is not normal with PCOS. What you should look out for is, do you have a co-existing condition? Do you have endometriosis or fibroids and adenomyosis and pelvic infections and things like that? People often just will put one label and then, you know, you're suffering for a long time. You may have pelvic floor dysfunction, you know, and that's what's causing the problems, body image issues, so many conditions, situations. And we talk about all this in the book because while the book is a deep dive, people can just pick up and read different chapters that they want to simply because, you know, you want to learn more about the condition, the bits that affect you. So that's what we did. We tried to break up the book into different bits with case studies.
Dr Rupy: Yeah, that's that's going to be exceptionally important, I think, for people who are trying to join the dots, as you described earlier, that Rohini was doing. Can, just on the point around pain and painful periods, because I think that is a very common misinterpretation of what PCOS is, even amongst healthcare professionals. I think they would will the painful periods away with a total diagnosis of PCOS. Do we have a sense of the coexistence of PCOS with other painful, other other conditions that lead to painful periods?
Dr Nitu Bajekal: Yeah. There have been a couple of studies to show that there is a link. These are all hormonal health conditions. They're all oestrogen-driven. So you can imagine that there is the problem, Rupy, is research is really crestfallenly very inadequate in women's research, considering we have a whole OBGYN specialty. And so, but in my own clinic experience, I do find more and more, it really depends on how much time you spend with the patient, how much time you spend listening to the story that you can actually pick up. And so I do find that there is increasing, certainly as I am becoming more aware over the last decade or so, I've been picking up more women with co-existing conditions. And so it is, you know, I hope somebody will do some more research in this area. But certainly, if you are having painful periods, please don't just assume it's PCOS, but instead, you know, look out for other things. Ask the questions, you know, people, as a health professional, as a doctor, it's our duty to answer your questions. And if we are not able to, then refer on to somebody who does know, because this joining of dots, hopefully when we talk about symptoms, I'll explain why it is so difficult to join the dots, which is why I want, you know, the person with PCOS in the centre actually saying, you know what, this is what I think I have, because none of you are seeing me, you're seeing me in these different little groups of different conditions and nobody's telling me that actually there is a common thread here.
Dr Rupy: Yeah, yeah, exactly. And and and on the subject of that common thread, let's talk a little bit more about insulin resistance because I think this is not only one of the potential driving forces behind PCOS, but a whole host of other conditions, right? So everything from type two diabetes, dementia, cancer, there are links with this insulin resistance phenomena. Um, you know, you've mentioned a few of those different drivers behind or the cause of insulin resistance, one being environmental, genetic, there's also lifestyle factors, environmental toxins, sleep as well. Um, let's talk a little bit about exercise in the context of insulin resistance. What what are what are the things that we know can potentially help us improve our sensitivity to this important hormone?
Dr Nitu Bajekal: Exercise probably plays one of the key roles, I would say, to improving your cells becoming more sensitive to the action of insulin. And it works in many ways by modulating your glucose levels, but also improving the uptake of insulin. And we know that strength training or resistance training, especially in those with PCOS and in type two diabetics, plays a particularly good role. So when you incorporate regular exercise and bring in strength training, ideally at least twice a week, working different groups of muscles, we know that the cells become more sensitive to the action of insulin, very quickly, actually. Similarly, you know, when you look at having had a meal, if you actually get up and even walk for 10 minutes, that improves insulin sensitivity. So very simple things that we often have this habit of having a meal, the biggest meal at the end of the day in front of the TV, and the blood sugar levels never drop enough. So learning to eat within the circadian rhythm makes a very big difference for those with PCOS and those who have issues with managing blood sugars, but actually who doesn't in this modern age, you know, with all the stresses and things. So exercise, definitely a very big tick. Aerobic is also very good. In people with PCOS, doing high intensity interval training may not have the same benefits, unless you're very used to it. Cortisol levels can rise, can worsen inflammation. I would always say listening to your body and at different parts of your cycle and actually doing more, you know, energetic training in the first half if you wanted to, but more gentle training, yoga, Pilates, strength training, you know, in the second half. And strength training throughout really for everybody, you know. I'm menopausal and I always tell women in the perimenopause and menopause, bring in strength training. It's one of the things that will keep your muscles working. And as we know, one in three people will die from a hip fracture, women from a hip fracture. So you want to build those muscles. And so it's for every age group. But PCOS particularly, exercise and insulin sensitivity is, and we have a whole chapter dedicated to that because insulin resistance is complex. It's genetic background, but also carrying excess weight really fuels the fat that is blocking each cell. And so when you lose a bit of weight, what happens is that fat moves away from the the receptor site and so it's like, imagine glue being stuck into a keyhole, which is the insulin receptor, and insulin is the key. So when you remove that gum or glue, then it works a bit better, the key turns a bit better. So that's why, you know, exercise, while it's not good for losing weight, it helps with improving insulin sensitivity, but losing a bit of weight also helps to improve insulin sensitivity. So body weight does matter for insulin resistance, genetics matters, also the foods we eat. So when you eat foods very high in saturated fats, they also will worsen the effect of the cell, the way it reacts to insulin. So I hope people are getting a little sense of why insulin resistance is so important in polycystic ovary syndrome.
Dr Rupy: Yeah, absolutely. And I think, you know, with all subjects in nutrition, it's influenced by a multitude of different factors, which makes it quite confusing for a lot of people. Um, you mentioned age there and I think, you know, when when you naturally age, you you lose things like lean muscle mass, you naturally lose your diversity of your microbes. And so a confluence of all these different things, a reduction in your immune system, etc, etc, leads to more inflammation, more insulin resistance and the great preponderance of all these different things that we know it's related to. So it's it's a really important sort of just a broad strokes idea to understand all these different influences whilst we dive into these specific subjects. So exercise super important, genetics, something you can't really change, but something that you can definitely manage with or better manage with with better knowledge. Um, I want to talk a little bit about the gut microbiome before we go into a sort of more holistic diet picture because there is emerging research around the gut microbiome, which is this population of microbes that live in and around our body, largely in our large intestine. And these microorganisms play a role in insulin resistance and disruptions to this gut microbe can lead to overgrowth of certain bacteria that are less favourable, which can cause inflammation and and alter the way our our body uses glucose. Um, I wonder if you could talk a bit about the the microbiome in that sense.
Dr Nitu Bajekal: Definitely. The gut microbiome is critical in hormonal health conditions. We know that in polycystic ovary syndrome, in endometriosis, if you look at samples of the gut bacteria, the vaginal bacteria, as well as bacteria from the peritoneal cavity, we know that there is a higher incidence of the ones that do not really bring health, you know, groups like Shigella and things like that, Salmonella. So we know that there is disordered microbiome in PCOS. But we also know that there is a gut microbiome called the estrobolome. I don't know if you're aware of it. These are gut bacteria that specifically synthesise and metabolise oestrogen that comes into the gut, which is normally meant to be absorbed and meant to be digested and excreted out. So you don't have excess oestrogen. We know excess oestrogen from our body fat, from some of our foods can actually worsen the situation for us by increasing our risks of breast cancer and other oestrogen-fuelled conditions like PCOS, fibroids and endometriosis. So actually nurturing the gut microbiome by avoiding advanced glycation end products such as, you know, fried foods and fatty foods and really increasing the amount of fibre in one's foods, which, you know, fibre is found only in plants. So trying to eat a wide diversity of foods, rather than just sticking to a narrow number of foods, because most people tend to eat, you know, the same six or seven dinners, you know. So, it's it's really thinking about what can I put on my plate. I absolutely dislike what I should not eat. I don't like the what I should not eat. What I want to know is what I should eat, what should I put on my plate. And so I encourage all my patients to put more colour on their plate. And so I see patients every single day, Rupy, where teenagers will tell me they hate fruit or they hate vegetables, or older women will say we are scared of fruit because we've heard fruit contains sugar. And so I have to spend a lot of time dispelling those myths, but also meeting the patient where they are at. So if a teenager tells me she hates vegetables, I ask her, okay, do you like cucumbers? Oh, I love cucumbers. Okay. So why don't we have a plate with cut up cucumber after school every day? And she said, oh, I can do that. And I like peas too. So the following week you add some peas and then you add some carrots. And and then slowly you start building up without them feeling overwhelmed, telling somebody to have 10 to 13 portions of fruit and veg. 10 to 13 portions of fruits and veg is actually not a big deal. It's about four or five fruits and a big salad. But telling somebody who doesn't allow a single piece of fruit to pass through their lips because they're on some fancy diet, you explain to them, do you like oranges? Oh, I like satsumas. Okay, do you mind having a couple of satsumas? We know they reduce the risk of endometriosis. So, oh, I can do that. Okay. So do you think you could add a bunch of grapes to it? Oh, I love grapes. I thought they're so sugary. And so suddenly they're starting to eat some berries and some mangoes and some grapes. And you've got them on the path and they're challenging themselves and thinking, I need to put colour on my plate. That's what Dr. Bajekal has said. So it's just understanding that. Once you understand that, I think it becomes easier and not so overwhelming, not so judgmental on yourself, you know, that I've been a bad person, I ate a piece of cake. So what? You know, you're allowed treats. Everybody's allowed a treat.
Dr Rupy: Yeah, yeah, absolutely. And and I I love that sort of holistic perspective you take of of eating is not just one way, it's, you know, meeting people where they're at. And I think, you know, that speaks to your decades of of experience in in clinical practice and seeing so many people because you can't brute force this. And I think social media in particular sort of paints a very stark picture of what your diet should and should not look like. And in reality, it's flux, right? You know, I'm going to I'm going out tonight to a Thai restaurant. I know there is something on the menu in the dessert section that I absolutely love. It's this like mango parfait thing. And it's full of sugar. It's got it's got all the not from the mango, but from all the other stuff they put on it. But I'm going to be eating that and I I'm I'm doing that in the full knowledge of the impact on my insulin resistance, but over time, it's the consistency of one's diet that really has the the impact on moving the needle.
Dr Nitu Bajekal: It's not one meal, Rupy. And it's not one or the other. It's not one or the other. You know, people often think it has to be just one way. It doesn't have to be. Just like Western medicine can go side by side with lifestyle medicine, similarly, a treat is a treat. You know, you're allowed to have that treat. And and that's why they're called treats. They're not meant to be everyday foods. Yeah, yeah, yeah. You know, I think it's important to to understand that.
Dr Rupy: Yeah, yeah, absolutely. And I I I think it's it comes down to what we were discussing earlier about the lack of nuance and the sort of loose associations that one might make if they don't understand the science. It's kind of like, you know, cholesterol and phytosterols. You want to have phytosterols. You wouldn't reasonably think that if you eat phytosterols, your cholesterol is going to go up or your LDL, your your carriers of cholesterol are going to go up. So it's the same thing and actually that's been demonstrated to be beneficial in the portfolio diet and a whole host of other diets as well. So, yeah, I'm glad I'm glad we've we've touched on that for sure. Um, although I'm sure there's going to be lots of other questions based around soy that we have to tackle. But you you've gone through a lot of them in your book. I I I imagine, you know, when you talked about um these sorts of ingredients in in your patient's diets, uh your patients have come back to you and like, you know, Dr. Bajekal, I uh I've tried to get more beans in my diet, but I just bloat, or I eat this way and I just bloat. You you've got some tips on how to avoid bloating as you inch toward, I love that term, that inching toward a whole food plant-based diet. What what are some of your your tips that you you talk about?
Dr Nitu Bajekal: The other thing I want to mention, Rupy, is that, you know, just because one has been diagnosed with any condition, it does not mean you can't eat culturally appropriate foods. You know, every single diet, especially a lot of our diets around the world, whether it is an Italian diet, whether it's an Indian diet, whether it's, you know, Southeast Asian diet, doesn't matter. There are a lot of beans and legumes in these diets, but also you can enjoy those foods. I want to enjoy my idlis and my dosas, rather and my, you know, different types of rotis and dal dosas. I want to eat that. I don't want to always be having avocado on on sour dough bread, you know, for a treat. So I think it's important to know that all these foods can be adjusted. And that's how I, when I changed my diet because Naina, our younger daughter decided to go completely plant-based when she was 10, I brought in so many world cuisines which I never knew existed. And so for those who are struggling with beans or any legumes, start with the smaller beans. That's what Rohini explains. Always start with the dals because they're smaller, they're more easily absorbed. Start with making sure that they're completely cooked. So they should be soft, mashable with the back of your spoon, whether whichever bean you're eating, because undercooked beans can give you a terrible tummy. The second thing is start, so making sure that you rinse your beans from a can thoroughly, cook your beans, soak them in hot water or in water and come back in the end of the day or overnight and then cook them. They cook faster, easier, they're softer. Start with just a teaspoon. Start with a teaspoon on your salad or something, and then make it a tablespoon, then make it two tablespoons. The same approach that I have with my patients. You don't eat any vegetables, start with one vegetable that you like. So same way, start with a teaspoon, then two teaspoons or a tablespoon, and then suddenly you're eating three bowls of dal and, you know, two bowls of lentils and there's no problem. There are certain spices that I advise. One of them is called hing or asafetida. It's got a funny little smell, but you don't smell it once you put it in and you just need a little pinch. You know, I had to change all my recipes from a pinch to a quarter of a teaspoon because I'm so used to just throwing things in. So when I teach cooking in the community class in Maiden Hackney, I have to really think about the amounts that I use because I said, I'm a lazy and a quick cook. So I have to really adjust to that. So using some asafetida into your while you're cooking your beans or into the tarka as we call it, the seasoning, can really help with reducing bloating. And again, making sure that you are avoiding foods like dairy and things alongside because what happens is the gut microbiome is completely different in those who have a plant-based diet versus somebody who's having quite a lot of animal products. And that can give rise to because those bacteria don't know what to do with beans. And so you can have a lot of bloating. So introducing them slowly over a period of three to six months, as you slowly replace some of the other foods, you will find it much easier. I haven't come across too many people once they adopt this. The problem occurs, I think, when somebody watches a documentary, you know, and goes completely plant-based or vegan and they don't know what to do. They just remove the meat from their diet. And so the star of the show, which was the meat, is now gone and they don't know how to bring in the plant protein or how to bring in a beautiful variety of plant foods that just fills your heart with joy. It's a joyful way of living. There's no deprivation here. I can tell you, I eat everything that anybody else on this planet eats, you know, in different forms. So I I just think it's useful to remember that that it has to be a journey. You have to do it slowly if you want to sustain it five years, 10 years, 20 years, right until the end.
Dr Rupy: Yeah, yeah. I I think those are those are awesome tips and I think the speed at which one transfers or changes their diet has a lot to do with the bloating. I always say that, you know, you've got to go slow when you're increasing the fibre content of your food and you're adding new diverse sources and try different things as well, but in small amounts. So I think that teaspoon to tablespoon to, you know, maybe half a can. I mean, I have a lot of beans in my diet and I'm I'm completely fine with bloating, but that would have been very different had I had a a very heavy animal-based diet. And actually a lot of people, I don't think realise just how many animal products they might consume on a day-to-day basis. My consumption is very, very low, but most people unconsciously will consume smoked salmon in the morning, a couple of eggs, you know, chicken for lunch, and then maybe like, you know, a steak at dinner. A lot of people are having this kind of diet, you know, it's completely reasonable and normal, quote unquote, but actually when you when you start changing it, that's when you see the the bloating and and stuff. So, yeah, that those are really good tips. Apart from, yeah, it's like, you know, when you're bench pressing, when you're bench pressing, for example, you don't suddenly bench press your whole body weight straight away, right? You've got to slowly build it up. That's the analogy to use that you can't or you don't suddenly run a marathon if you haven't even not able to run to the top of the road. You just can't. So, I think that is the the people want very quick fixes because they're often promised by people who don't really reveal all of themselves in social media. And what happens is you're suddenly seeing this person who's at the perfect size, the, you know, everything seems so perfect and they're eating this, you know, huge salad, which is great, but they've been doing this over time. So how can you suddenly jump to that when you haven't eaten any of that foods? You wouldn't do, as I said, you wouldn't run like that and you wouldn't lift weights like that. So don't do it with with food either. And and also you don't have to start with food. There are six lifestyle pillars. So I often, my my way of approaching when I talk to patients is I never start with food. I'll say, I after I've asked them their gynae history and their general history in about five minutes, what I always ask them all the general stuff and then focus in on the gynae stuff because otherwise I can get distracted and forget that they're allergic to penicillin or something like that. So I have a system that I I actually work through. And then I say, would you mind if I ask you a few questions about your lifestyle? And I always start with sleep or and stress and exercise and their alcohol intake and their smoking and their community support and then go to nutrition because then people don't feel so judged. Nothing makes people feel as judged as to what you eat. You know, you're always apologising either for being a vegan or for being plant-based or for eating a steak. You know, we're always apologising for things. So I think it's better to work this way. And also by maybe focusing on if for me, of all my lifestyle pillars, sleep is absolutely, I always say, I'll sleep when I'm dead. Most of my life, I've slept four or five hours. I know it's terrible. It's probably the thing that's going to kill me very quickly. But that is where you want to focus a pillar that somebody is actually interested in. Oh, I think I do want to do 10 minutes of an app where I will do some mindfulness or I'll go for a walk. I can do that. And so what happens is the domino effect. When I go for a walk with a friend, I laugh, I I feel better, my stress levels come down. When I come home, I'm not reaching straight away for a piece of cake. I will say, you know what, I'll actually have a tub of strawberries. And so when you do that, you feel better, you then tend to sleep better at night. When you sleep better at night, you'll wake up and have the porridge. And so it and you'll not reach for the glass of alcohol. So I just think that working with people and actually focusing on perhaps the other five lifestyle pillars before you dive into nutrition, sometimes can be a nicer way and not making people feel judged that much at least, certainly, unless that's what they want to first, you know, you might give them a couple of tips, but focusing on one of the other lifestyle pillars might be a kinder entry into helping them empower themselves because, you know, we are as as humans quite harsh on ourselves, especially women. We're very harsh on ourselves.
Dr Rupy: Yeah, yeah. I um, I'm really glad you mentioned that actually because I I I think um, we all have our biases, right? Whether it's, you know, a particular way of eating or whether it's a particular intervention that we favour, you know, a particular lifestyle pillar. And you have to match that to where someone's at and what they're most motivated by. Um, so I think it's really important to remember that. And I this might be a little bit of a segue, but, you know, you strike me as someone who's um energetic, joyful. I mean, this conversation has been an absolute pleasure to to have. I mean, what what are the things that spark joy in in your life? Because, I mean, I've seen you on a few other pods, you know, I've met Rohini, it kind of shines through her as well, I feel. Like what what are the things that are like really giving you joy at the moment? And also considering the fact that, you know, you've been working super hard in the in the healthcare system for many years now. Where are you where are you getting your sort of sources of inspiration and motivation?
Dr Nitu Bajekal: It's not always like this. I can tell you, I have, I am an anxious person. I do love my own company. Um, you know, but I could not have been happier that I fell into medicine. I had no idea that I wanted to be a doctor. I was, I had polio as a kid and I recovered from it. It was just before the vaccine, so I'm, you know, 61 years of age, so long, long time ago in India. But my father really pushed me in the track and field events. So I was hoping that that's the road we were I was going to take. But of course, in India, there was no system to do that. So my brother and sister were doctors, so I became a doctor. And, you know, discovering OBGYN was the best thing that ever happened to me. I just find it just as thrilling as I did 40 years ago. But over time, I realised there was something missing in my toolbox and that was lifestyle medicine. So I then retrained, having gone through a very difficult time at the age of 38, you know, with premature ovarian insufficiency, menopause much earlier than my sister or my mother went through. And I didn't know where to turn. I'm very honest, Rupy. It was really hard. I couldn't share with my male colleagues and I should have because they were so supportive later. And I was always this overachiever, you know, I wanted the gold medal, I wanted to be the top of my thing. I never went part-time. I went back to work straight away. I had a fantastic support in my husband who I met in medical school in the first year. So, you know, we pushed ourselves. We were immigrant doctors, poor immigrant doctors, but we never thought we'd stay on in the UK. 30 years later, I'm still here. But, you know, I wanted it at my terms of being a consultant, reaching the top of my game, and really helping people. So I think my joy comes from a few things, from my family. I just adore my family. I adore my two rescue dogs. Walking them is not negotiable, whatever the weather. They get, you know, two hours from me and two hours from Rajiv always. The NHS was a great source of joy for me because I love the way it delivered care, free at point of care, and I love that. It's one of the main reasons I didn't go back to India. I do do private practice and I actually just retired from the NHS after 31 years, and I do still do a bit of private practice. But, um, I think the fact that I can, I want to reach a lot of people. If I can change somebody how they think, maybe help them, because I see that every day in my practice in medicine, you know, I see people who get their periods back, who get pregnant, who have health goals that they have achieved, they've come off insulin. So, you know, for me, that is something I want to take on a bigger platform, just because if somebody hears this, makes one little change for themselves or their parents or their children or their community, because women are great at chatting, aren't they, and sharing information. I just want that information to be out there. So that's what gives me joy. In my spare time, as I said, walking the dogs, watching endless box sets and chick flicks. I cannot watch anything that is remotely upsetting. My brain doesn't take it. I cannot. I start feeling for everything and, you know, it's it's not a good place to be. So worrying continuously about the planet, about animals, um, you know, I my mental health really suffers. And so I need to be outdoors. I play golf. Um, and I have a, you know, very good friend support, you know, I'm part of a book club and things. So, it it's it's tough, you know, people who think that, yes, I am very jovial, I am very upbeat, I love what I do, I'm very passionate and, you know, I have found the purpose in my life and I think if I hadn't gone menopausal that early, I probably would never have found it. So there's, you know, I do practice gratitude, however cringe that sounds, but um, I I think that there is a lot to be said about the different aspects and actually acknowledging, you know, I I went through therapy because my children said if there's one thing you can do, mum, go to therapy because I think you will benefit from it. You're always never putting yourself first, always pushing the boundaries. And I have to say it's been an absolutely enlightening experience over the last year or so because there are so many aspects that we we don't want to think about and talk about. And it's it's useful to know that, you know, not everybody is what they appear on the outside. There are a lot of things that do go on that, you know, and I think had I not had the therapy, I've recently had a few health issues in myself and in my family, which are all under control, but had I not had the tools to deal with it, I think I would have been in much worse place. And, you know, Rajiv's been an amazing partner, my soulmate. So I've been I've been very, very fortunate. And I want to use that good luck and fortune to try and reach to people. So I hope that didn't sound too long or cringe, but
Dr Rupy: I hear, no, no. I mean, I I I appreciate you sharing that. And I think it's very easy for people like I have just done there to assume if you're joyful on the outside, you're joyful in every aspect of your life. And I, you know, I think I was chatting about this with a couple of colleagues and and Owen actually on on the podcast about how I need to demonstrate slightly different sides to me because a lot of people would make the same assumptions about myself, you know, I'm I'm always jovial, I'm always excitable, I'm always energetic. But there are days, fairly often, I would say, during my week where I do get low and I do have a ton of self-doubt and I do self-criticise and I feel like I'm in limbo and I'm not moving anywhere or I'm not, you know, going to the next goal or I'm not being aspirational enough. And I think that plagues everyone and in particular certain types of people who find themselves in professions like ours, you know, in medicine. Um, and to know that, you know, you were in um competitive field prior to medicine, uh and you're already of that sort of that mindset, uh probably gives me a little bit more insight into into why you might be an anxious person as well.
Dr Nitu Bajekal: Yeah, I think what my father said to me always, Rupy, which I think my mother and father were really inspirational people, but a couple of bad things my mother handed down to me. She was, you know, they didn't have much money, but so she worked really hard. She was a head teacher and she held down three other jobs. But that was the role model I saw. And which I've handed down to my children, which, you know, there has to be a balance in one's life. You know, going back to work within a few days of, you know, having your first child is not something I would ever advise my trainees, not sleeping at night, you know, wearing it as if it's something really good. I'll sleep when I'm dead, is not something, you know, those are lessons that I wish I had learned all those decades ago. But the other beautiful thing that my parents would always say, especially my father, would say is he never brought me up to be competitive with anybody else. And I'm not sure whether it's a good thing to to sort of compete with yourself, but basically try to be the best person you can because, you know, there's always somebody going to be, you know, cleverer than you, richer than you, more beautiful than you, more successful than you. What are you going to do? You know, you have this one life, you've won this lottery of being alive, being alive at a time when, you know, I'm so fortunate to have health, to be a woman, not being in an oppressive regime, so many benefits, so many good things that are happening. If I'm going to look at the negatives, that's going to really drag me down. So that, I think, is really important that don't look at other people how they are doing. Look at yourself and think, how can I make myself happier? Will this, will the next book make me happier? If yes, go for it, but do it nicely because that's what I have to keep telling myself, you know, understanding that that is really the the critical bit is you have that one life, it's your life, and if you don't live it the way you want to, I can't be you, Rupy, ever, right? And you can't be me. So what is the point of trying to mimic somebody else's life? Because you're not going to be, it's never, nothing. Not your genetics, not your epigenetics, not your environment is ever going to let you do that. You'll just be miserable about it. And also understanding that you can't change the entire world. You can do it one person at a time, and that's what I have to talk to myself always because I can, you know, I swing through, oh my God, we're heading to doom, you know, the planet is gone. I have no, what is the point of me talking about all this? It's absolutely useless. And then, you know, then I talk to somebody like you and I'm thinking, wow, there's so much hope in this world. So lovely. I love the young people. Young people are the future of this world, you know. I have to say, I just absolutely adore the young people.
Dr Rupy: Yeah, yeah. Well, I'm a I'm a gratitude proponent. Like I I I share my my gratefulness every day exercises all the time with with friends, colleagues. I used to share it on Instagram. I should probably start again. So I'm a big, big fan of of um of gratitude. Um, and also, um, there is this concept, um, of uh, mymetic uh, behaviour. Um, it was pioneered by René Girard and I would definitely look into that, uh, because I I I feel that as humans, we have a natural inclination to mimic. It's actually how we've evolved. And I think when you understand why we compare each other or why we get FOMO or why we always feel that we need to benchmark against other people, it's actually part of our evolutionary drive. And when you understand that, then you can make um, uh, steps toward healing that because I'm, you know, I have to remind myself that comparison is the thief of joy pretty much every day. And I and I think, you know, we were joking about it earlier, and there is sort of a running joke, particularly amongst people who come from an Asian background, whether it be Sri Lankan, Indian, different parts of China and other parts of Asia, that uh the the parenting sort of technique is if you've got 98%, you're missing the 2%. And where's that 2%? Why didn't you get that 2%? And I think the the the use of words and terminology that's banded around, even casting the the lot in ourselves with the word PCOS, the the abbreviation of it, you know, it can create an incorrect picture of actually what's going on. And so you're right. I think just being aware of the terminology and and actually how your body is reacting and what is driving the condition, I think is really important.
Dr Nitu Bajekal: And I was so grateful to my parents for that. They never did that, but I've seen it all the time. You know, I was a terrible parent myself in the sense that the girls basically brought themselves up. Seriously, Rajiv and I were the world's worst parents, I think, because we were so busy with our careers, the girls literally brought themselves up and thank God they did because they did a brilliant job because you know, they were too clever for us and we couldn't answer half their questions. So, you know, it it was absolutely fine whatever marks they got because we never saw what they got. But it is a it's a recurring problem with it is.
Dr Rupy: And and I I feel that there needs to be almost like another division or at least an appreciation within um therapy that is practiced in the UK or US or if you like to call it Western therapy for people of Eastern backgrounds, um, you know, particularly immigrants. I think there's a a real lack of appreciation for those sort of um households and and how parents interact engage with their kids and what is regarded as the norm. And I've had therapy sessions where I've basically had to explain the the typical Indian or Asian household for a couple of sessions before they actually appreciate that's where you might have trauma or, you know, ingrained beliefs that are not helping you in the present and and your day-to-day. So, yeah, we could probably go off in a completely different direction, but I'm going to bring it back.
Dr Nitu Bajekal: You're right. I mean, I'll just want to say this. Naina, I remember when she was young, or even recently we had a chat, my younger daughter, and I said, I never put any pressure on you. Dad and I never put any pressure on you. And she said, yes, you did, just by being yourselves, just by being Indian, just by being the doctors that you were, you put pressure on us. You do not realise. You think that's not pressure, that is pressure. And that's the same with health things as well. I think there's not enough appreciation of the stress that generations before us and generations like myself have come in, the stress that it has on our health, on our environment that we pass on to our children. Those things have not been appreciated in research, have not been appreciated in nutrition, in so many aspects that I think I'm so glad to see people of colour now in in platforms where they can hopefully make a difference where you see somebody who looks a bit like you, who is has got the similar background to you, which allows you to then say, you know what, I can also do this, like you said with the mimetic behaviour.
Dr Rupy: Yeah, absolutely. Nitu, this has been wonderful. We'll have to get you in the kitchen studio whenever it's built and whenever it's ready and stuff and you can cook up some of the dal and the idli and dosa, whatever you want to cook. I'm sure it will taste absolutely fantastic. So thank you so much. I really appreciate it.
Dr Nitu Bajekal: Not at all. Thank you for having me on.
