Deepak Ravindran: Right now, pain is responsible, especially musculoskeletal condition pain, which is pain due to arthritis, rheumatoid arthritis. It's accountable for almost 5 billion pounds of NHS spend per annum. It's accountable for almost 20.8 million work days lost. It's the second most common cause of sickness and loss of job and productivity in our economy as it stands. And it is the third most common reason for the visits to any kind of primary or secondary care setting. So we do need to do something about it that is system-wide, rather than stacking all the expertise in one corner, which is relatively inaccessible, not well-resourced, and not well-supported.
Dr Rupy: Today we're diving into how nutrition intersects with the complicated world of pain. Today I've got former guest and colleague Deepak Ravindran to talk to us about how our immune system can impact our perception of pain and the different types of pain patients. And I think when people think of a pain patient, they have a stereotypical type of person in mind. But actually, we're going to be talking about a range of different topics, including IBS, pelvic pain, chronic cystitis, fibromyalgia, migraine, functional gut disorders, long COVID, and more. And we're also going to be talking about how we can do better as medical professionals in the management of chronic pain. Pain cannot be explained by a singular pathway, and I think there's so much that we could all learn from Deepak's insights on the topic. Today, we discuss the different types of pain patients, how the immune system trains our responses to pain, and how trauma in childhood can actually impact our responses and why food plays a pivotal role. If you don't know, Deepak is an honorary professor at Teesside University and has worked as an NHS consultant in pain management. He's also the author of The Pain-Free Mindset, a fantastic book that I recommend to both patients and medical colleagues. And his new role is Director of Lifestyle Medicine for a primary care network of GP practices in Reading, working upstream to bring these insights into the chain of pain management.
Dr Rupy: Let's talk about nutrition and pain management. What is the relationship between what we eat and our perception of pain and even, you know, better managing pain itself?
Deepak Ravindran: Thank you, Rupy for that question, really, because to answer that one, first of all, a lot of the public and a lot of my colleagues themselves did not understand that there could be this potential link between how and what we eat, when we eat, how much we eat, and how that can have a big impact on the intensity of pain that we feel. And for that, I probably, if I can digress or sort of go one step upstream, I'd want to say, well, what has changed in our understanding of pain to say, well, why is nutrition now so important? And I think that comes from a couple of discoveries and understandings of the human body and the neuroscience that has happened in the last probably 10, 20 years. Principal among them is our understanding that the immune and nervous system is very, very deeply connected, and that there is a representative of the immune system in our brains called the microglia, and these are present at every synapse, every junction between nerve cells in our brain, in our spinal cord, you have these representatives of the immune system. So that's kind of the first thing that we were taught in our medical school that our brain is an immune privileged organ, that there is nothing of that nature. But we now know that there is a deep connection and link. Why is that relevant? Well, 80 to 90% of our immune system is in and around our gut and intestines. So if you're saying that chronic pain has got something to do with how the nervous system is functioning, then the immune system is being modulated and modified by what we probably eat. And that's a connection that has come through the understanding of this link and the understanding that the immune system is in the gut, in and around the gut, and that there is a lot of conversation happening between the microbiome, you know, the various microorganisms that are there in our intestine and the immune system in our intestine. So therefore, the health of our microbiome can make a difference in how pain is perceived or managed. Now, that is something that's still not common knowledge. And there are certain mechanisms that we've now understood to say, well, how can nutrition make a difference in pain management? The second thing that is going back to our understanding of pain is for a long time, we've had conditions, for example, a prototype would be fibromyalgia. We've always been taught that for some conditions of pain where there is acute inflammation, so like osteoarthritis that is having an active flare up, or you had a surgery or you had an injury, we are very familiar with the fact that you have chemicals that are released at the site, and we call that nociceptive pain. Sometimes we have nerve damage, like with people with diabetes, or if you've had a stroke or MS, you know you've had nerve damage or a surgery has cut a nerve, then you have a neuropathic pain. But for conditions like migraine, headache, irritable bowel syndrome, fibromyalgia, some forms of pelvic pain where you don't have any evidence of active inflammation, but you also don't have any suggestion that a nerve has been damaged or cut. We've struggled traditionally and scientists, researchers, clinicians have struggled to say, well, what's happening? Why is somebody feeling pain? And we've never been able to demonstrate it until the last 10, 15 years when the neuroscience and the MRI imaging of the brain has shown that actually there is an excessive signaling. So we've had to give it a new name, and that new name was coined in 2020 by the International Association of Study for Pain, that's kind of our flagship organization. And it said, well, let's call it nociplastic pain. That is effectively the nervous system is plastic. It's kind of become sensitized, become over sensitized, if you will, and that can be modulated or that over sensitivity can come from different sources. And one of the principal sources is the immune system. And so that kind of goes back to my first point where saying where the immune system is being modulated by the gut and what we eat. And now we know that nociplastic pain, one of the big modulators is the immune system. So this is where sort of we're bringing it together and saying what we eat can make a difference because if somebody's diet is kind of the standardized American diet, is kind of more filled with high energy or low fiber or ultra-processed foods, it ends up disturbing the diversity of the microbiome. It induces this state called dysbiosis. And I know the leaky gut, I've listened to some of your pods before where I know that some of your other guests have been concerned about the use of the word leaky gut, and I completely agree. I think it's a little bit, but it is a popular term. It's people understand it. But that leaky gut, that disturbed diversity of the microbiome, that change in the lining of the intestine, all of this tells the immune system which is monitoring our situation that there is danger, that there is threat. The immune system then says, well, if there's danger, if there's threat, I must inform the nervous system. And it informs the nervous system through the vagus nerve. The chemicals that are released at the site, the various inflammatory molecules that are released at the site, some of them may be coming from the metabolites that some of the harmful bacteria or microorganisms might produce, and they make their way into the circulation, that might travel through the bloodstream. So you have this collective barrage of information that informs the nervous system that it's time to get sensitized. I'm getting sensitized. I need to do something about it. And pain, we understand, is now to be considered as a form of protection, is a form of information about distress from somewhere. And that's what is the relationship we're now understanding that if your food or if the kind of nutrition that you have is not optimal, it has this knock-on effect on the immune system, and in some people, it brings about this condition of nociplastic pain that then is manifested in different parts of the body with varying intensity, and people often can't find it in a blood test or a scan. And that complicates matters, but as people understand about this better, it becomes easier to understand why nutrition plays such a critical role in many kinds of pain management.
Dr Rupy: Absolutely. That's a beautiful and eloquent explanation as to the connection between nutrition and pain. I just want to clarify for the listeners out there, you mentioned microglia right at the top of that. We've heard on this podcast microglia being sort of the glue between neurosynapses. And you mentioned microglia being present in other sites of the body and how that's got a connection with the immune system. I wonder if we could just dive into deeper into what we mean by microglia and that role within that pain pathway.
Deepak Ravindran: Absolutely. Now, for a long time, we were taught that microglia, exactly as you said, they are sort of the buffer, the shock absorber, they're the glue, and they are there quietly supporting our nervous system. That was the impression. What we now understand is that the microglia are a representative of the immune system. And when our body was forming as a fetus right inside our sort of in utero, the first 9 to 11 days when the blood brain barrier hasn't yet formed or come into place, the microglia comes out from the nervous system that is part of it, goes into the brain and the central sort of nervous system and gets to stay there. We haven't still figured out how they are able to communicate, the different ways they communicate, but it is fairly clear that if something happens to the immune system in the body, the microglia get to hear of it. And the best way I can describe it maybe for your listeners is imagine that these microglia have a lot of surveillance cameras on them. In the research field, we call them toll-like receptors, TLRs. And these surveillance cameras are detecting patterns. They can detect different kind of patterns. They can detect patterns that come from molecules that are released by harmful bacteria, so pathogen associated. They can detect patterns that come from damage. They can detect pattern that come from foreign substances or toxic substances, and they can detect patterns that also come from emotional changes, so behavior. So you have these kind of, I think they call it pathogen associated molecular patterns, PAMPs or DAMPs or ZAMPs. And these are the surveillance camera functions. And when the microglia, this representative which was thought to be just an insulator in the spinal cord and in the brain, when they receive this information via the surveillance cameras, they turn, they change. In my book, I write that they change from like a nice Dr. Jekyll to a Mr. Hyde. So they can become different forms. And there's a very eloquent description by another author called Donna Jackson Nakazawa, who actually likens them to an angel and an assassin. So microglia, when disturbed in one way, they can either become one form of microglia called M2, which would be anti-inflammatory, it would release all kinds of protective stuff, or it could become an M1, which would become pro-inflammatory, it would release all kinds of inflammatory chemicals that would cause collateral damage in the synapse. Now, what does the synapse do? The synapse is the junction point where instructions and chemicals come from one end of the nerve and it jumps across this junction and then it carries on. Now, at the junction, if this microglia has changed into a Mr. Hyde, it's causing more inflammatory chemicals, then the signal that's supposed to come along gets confused. It may not be transmitted efficiently in the same intensity to the next nerve that's supposed to take it up further for processing so that the brain can make sense of this signal and give it the accurate information. So the signaling and the messaging starts to get garbled, confused. Now, depending on which circuit and which part of the brain this is, if this is the memory circuits, this could explain some of the fibro fog or the confusion and signaling that comes. If it is the motor circuits, then it might be resulting in fatigue. If it happens in the circuits that mediate hearing or vision or other emotions, you can have changes in the signaling, and therefore the actual output and information because everything the brain's using this information to make predictions on what to do next is all corrupted or confused because the microglia is acting on the surveillance information that's come through. And this is the change that we're realizing that how do you calm it down? Now, the good thing is that this change of the microglia to an assassin or to a Mr. Hyde form is reversible. It's not a one-way street. If you can change the settings, the optimal settings, whether it's nutrition, whether it's sleep, whether it's stress, whether it's the damage or the pathogen bacteria or microorganisms, the microglia can go back to its usual or normal or anti-inflammatory form, and that means healing can occur. And in pain terms, that means recovery is possible. That means pain can reduce. That means you can become pain-free. And increasingly over the last five to eight years, especially I've been now a consultant for 14 years in the NHS, I've been doing and looking after pain patients for more than 20 years now, I'm seeing and hearing and meeting patients who are saying they have become pain-free after 5, 10, 15 years. So recovery is possible. There are changes that can happen, and I think a lot has to do with how the microglia can reverse and then set the stage for the condition itself to reverse.
Dr Rupy: You mentioned, you know, your extensive experience within the NHS and within this field. When did the penny drop for you that this was actually possible through lifestyle and nutrition means? Because I imagine, like myself, you weren't taught this at medical school, right?
Deepak Ravindran: No, no, no. It's a lot of our learning that we have to do. And I think like what you were saying, we have to stay eternally curious. And we realize that there's so much information that's come through now that it would not have been possible for us to learn this. And I don't think what our present trainees learn in medical school, that knowledge is likely to be outdated or has to be updated every three to five years anyway. So I think it is a fallacy for us to believe that one part is enough for us. I was what I finished medical school back in '98 in India. I then came to the UK, went through my training here in the Oxford region, started as a consultant in 2010 with a fellowship in pain medicine from UCL, from Stanmore. And I was taught everything that was the state of the art at that time. But within the first three to five years as a consultant, so 2015, 16, I was realizing that the skills that I had, the tools I had, which was the ability to inject or do nerve blocks or prescribe optimum dosages of certain strong medication or have good conversations with patients, were just not enough at all because that wasn't addressing the pain of these patients, whether that was coming from musculoskeletal conditions, whether that was coming from some other nerve damage, it just wasn't enough. And that's what made me realize, well, what have I not learned? What have I not understood? And what's missing? Because if I did anything, whether I give a drug or an injection, within three or four months, they'd come back and say, it has not worked or it stopped working or can I do it again? And we were realizing that our system, the NHS as it was doing, was not going to be sustainable with repeating something every two to three months or giving potentially strong drugs like opioids or gabapentinoids, which we were starting to realize were not good as we understood it or not safe as we thought it would be. So how do I change? And that's when when I went back to seeing, well, what's happened in the research field? What's happened in the literature is where all this information. So 2016, we're now recording this in 2024. It's taken me about four or five years to learn this first of all myself before applying it to patients. And then after my book came out, I've been sort of talking about it, getting the chance to implement it. And then I keep hearing these stories of patients who have done it, who have actually gone ahead and implemented these principles, gone ahead and tried something else other than drugs or injections, or sometimes alongside drug and injections, but have seen remarkable changes and sometimes having complete freedom from pain for some groups of patients. It's by no means a playbook that I can say if you do this predictably that will happen. It is unique, it has got to be individualized, but now I'm more confident that people can become pain-free and there are certain set things that they can do, and I think nutrition and lifestyle is a very critical piece in that.
Dr Rupy: So across your experience, and you mentioned at the start of your explanation here that you've got your patients who have physical causes to their pain, whether that's osteoarthritis or an injury, trauma, let's say. You have neuropathic pain, the severing of nerves. And then you have a collection of patients who suffer IBS, fibromyalgia, migraine, and there isn't a clear cause. How much of the immune nutrition connection is there across these different patients? And is it overexpressed in one of them? And I guess the follow-up question is, is one's experience of pain in some way dependent on their lifestyle? So if I have osteoarthritis, can I have a better experience of that pain if I optimize everything else around my lifestyle as well?
Deepak Ravindran: Great question, Rupy, and I think I'll start probably with the last bit there, and maybe if I forget a couple of things, you might have to repeat it for me. The first thing is about osteoarthritis. For ages, we were taught or we still, the perception is a wear and tear. And I want to really introduce that or maybe your listeners, hopefully I've heard it from others as well, is that we now need to reframe it as a wear and repair. That the changes that happen as we age in our joints is a dynamic process of our immune system talking to our body and trying to repair the changes that happen. So a thinning of the cartilage or a change in the ligaments is also followed at the same time by the body and the immune system attempting a repair process. And so this wear and repair is very critical because that means we should not think about osteoarthritis anymore as, oh, my dad had it, my uncle had it, it's in the family, and so I've got it and this is me for the rest of the next 20, 30 years. It is not at all a done deal. If you can take that opportunity and say, well, my immune system is doing its best to repair, what can I do to enable that repair process? What can I do to optimize to give my body the best chance of the repair process? And that opens up the conversation to say, well, how can you calm the nervous system down, reduce the chemicals that are produced? And how can you calm the immune system down to change the immune system to make it more powerful or more able to promote repair in any arthritic looking joint on an x-ray or an image? And that opens up the conversation that, well, if you want to calm the immune system down, I think nutrition hands down is the best way forward. If you want to calm the nervous system down, there are non-drug ways of calming the nervous system down, which is where all these stress management strategies or behavioral strategies or relaxation techniques, sleep optimization, physical activity and keeping, you know, exercise of some form, movement-based strategies are all critically important because they help build new nerve circuits, they modify and prune existing circuits and release or take away unwanted circuits. So I think that is the critical foundation of how we think about osteoarthritis, wear and repair process. So what can you do to enable and promote the repair process? That kind of feeds into, I think, the first part of your question wherein, I think if you, if I remember right, you said, well, out of the three types of pain, where is the potential for this lifestyle optimization the most? Nociplastic pain, the category that is newest, that is because of a nerve sensitivity and over sensitivity, if you will, of the nervous and immune system, is the one that lends itself most to the lifestyle optimization picture, clearly. There is certainly a role in nociceptive pain and even in neuropathic pain for certain drugs to be added, maybe certain procedures or injections or infusions to be done at the right time for the right patient for the right duration. But by and large, you're not going to get long-term improvement for those conditions by just doing only the drugs or injections. That's why it's still worth doing the lifestyle optimization for that form of acute nociceptive pain or even neuropathic pain. And that change is coming. So for example, where you know you're going to get nociceptive pain, for example, people waiting for surgery now, the waiting lists are going up, people who are recovering from surgery and you don't want them to have lots of opioids or too much opioids in the time that they are in hospital or they get discharged from hospital. The concept of prehabilitation, how can you prepare somebody before they come for surgery? How can you put in measures of activating their immune system, calming their nervous system so that they have the best response to surgery, so that we don't have to use too many opioids or strong drugs during surgery, and you keep their immune system in the best way possible to promote healing after surgery. All of that is now being looked at, and indeed, the center for perioperative care, which is like our main organization in the UK looking at saying, how can we optimize waiting list? They are taking up this option of saying, well, how can you use the lifestyle medicine principles to ensure that just waiting for surgery doesn't mean you just sitting on a couch, not doing anything because you're afraid to move and let's wait for the surgery, let's not do anything. What can we do to prepare ourselves? How do you reframe waiting list as preparation list? And that was part of the research that I was doing with my colleagues in the University of Reading as well to say, well, how do you go about this reframing? Because it's not so much a messaging thing, but you also then have to give them strategies. What can you do in a six-week period in the run-up to your surgery that would help, not just smoking cessation, but how can you do some gentle movement? How can you eat healthy? How can you do some breathing or relaxation techniques? And how can you make a habit out of it? It's not just doing it once, but it's about saying what are the steps you would take in place so that what starts off as once or twice a day becomes a habit that you can have in the run-up to surgery and start doing it and continue doing it after surgery because that is part of lifelong health.
Dr Rupy: Yeah, yeah. It's a real opportunity, isn't it? To actually encourage behaviors that not just improve their state of living in anticipation of an intervention, but also across a whole spectrum of other specialties, whether it's metabolic health, cardiovascular health, brain health, etc. So I think there's, yeah, within the waiting list, as horrible as they are, and I, you know, obviously we want to try and reduce them as much as possible within NHS, but there is an opportunity there, I think, to educate and encourage healthier lifestyles. Within the the patients, and I'm broadly classifying here, IBS and migraine and fibromyalgia, is there any semblance of how people might be more predisposed to these kind of conditions? So how they might be a little bit more sensitive? And this doesn't necessarily need to be within their lifestyle realm, but perhaps, you know, a genetic predisposition or something else that could be predisposing them to to suffering them?
Deepak Ravindran: Quite an interesting question, Rupy, and this is something that's been another sort of penny drop for me over the last maybe five, seven years, really, is exactly that thing like, why are some patients more prone to having IBS and all these nociplastic pain conditions? And I think the research is starting to throw up a few interesting, maybe sometimes a little controversial, but really irrefutable facts. And what we are understanding is that if you go back to the question, why is the nervous system and immune system sensitized or overprotective in some people? And once you sort of peel the onion on that, as it were, and you look at the layers, we are starting to see that there is this component of what could have happened to the nervous and immune system earlier in life. And how early in life, well, we are going back now to childhood. And there are now some studies suggesting, well, we need to go back to what the maternal diet or what was the psychosocial circumstances of the mother as the fetus was developing, what was she eating, what was her lifestyle like? Because it's not so much genetic, but it is, I think, the epigenetics, meaning you are, we all have a similar set of genes, but some genes get expressed in response to certain environmental triggers. And the expression or exposure of these genes results in different behaviors or different chemicals or different proteins that get released. And that epigenetic changes is also a form of sensitization of the nervous and immune system. If that child in the first three years, so there are these critical periods in the development of the child, the first thousand days, the time of puberty, and then the transition to whatever we might call as adulthood, all of these three are phases where there is a lot of what's called synaptic pruning, where a lot of nerves, nerve fibers, nerve connections are changed. And the way to think about it is we were thought, we were taught actually that again, the brain sort of develops and then gradually learns things over time and new fibers come along. I think the newer understanding, and I, this is my understanding of the literature and the reading, is that we are born with far more connections than we ever need. And so the young brain has got lots of synapses, lots of junctions, lots of networks. And then as the baby in the first thousand days or puberty or whatever, and the nervous and the immune system and the microbiome, everything that plays in the part here, as it gets exposed to various environmental conditions, you know, whether that's connection, whether that's the society, whether that's parental love or affection, all of that forms the basis on which the young brain keeps weeding out certain connections, reinforcing other connections, letting loose some connections. And that kind of pruning of the garden, as it were, occurs over the first 18 years. And it is during these periods, if the nervous system has been sensitized to a traumatic stress, if the child has been exposed to abuse or neglect or has witnessed familial dysfunction of any sort, then we now understand that that puts a lot of stress on the developing nervous and immune system. It affects the cortisol, the stress hormone production. It affects the growth hormone production. It affects the female sex hormone and male sex hormone production and expression. And those are the things that become unpredictable because then as the child goes through into adulthood, it might take a relatively small bacterial infection when on traveling to cause a bout of IBS that then continues to persist. It might be one episode of a urinary tract infection that never subsides because there's already a sensitized nervous and immune system and that becomes a pelvic, chronic pelvic pain. It might be a divorce or some kind of workplace bullying or a road traffic accident in adulthood that puts the nervous system on the road to getting sensitized everywhere and that gets diagnosed as fibromyalgia. And we are noticing these trends and a lot of my patients when they now come to my clinic, and I open up that chapter and say, okay, your blood tests don't show any signs. You're not responding to the usual medications we've given. And your x-rays are showing some signs of aging, but nothing to explain the intensity of your pain. Could we talk about? And obviously, these are sensitive conversations. These are conversations that can be had when you've established rapport. But invariably, when I have had that opportunity to explore that, it is surprising how many patients have opened up that chapter to say that yes, there are reasons why their nervous and immune system might have been prone to being sensitized from childhood due to a variety of circumstances. I'm not saying that that's the only reason, but that becomes a reason for some kind of sensitivity or predisposition or vulnerability. Again, it's not written in stone that that's what will happen, but it does mean that if we are aware that that's a contributor, then what can we do now to actually mitigate it?
Dr Rupy: Yeah. And you know what? I think that beautiful explanation will be validating for a lot of people who experience this quote unquote nociplastic pain. And I think what you've just to summarize what you've said here, you have an epigenetic driver potentially. You have the formational period within the first thousand days and the first 18 years where the growing individual is pruning and essentially providing a playbook of how they're going to navigate a very complicated world. This will have a knock-on effect on hormones and how these are expressed. And then you have a series of triggers that put into motion a cascade of events that could lead to diagnosis of fibromyalgia, migraine, or whatever it might be, an over-expression, let's say, of pain for various reasons. I think just opening the door to this being a possibility, not the cause in every case, but just the possibility that there is something, again, to use your terminology, upstream of a diagnosis that could be driving this, I think that's validating not just for patients actually, but any gastroenterologist listening to this, any neurologist listening to this, might also start to ask the questions of themselves, is there something else driving conditions that we otherwise don't have a clear explanation for, given the investigations, both, you know, blood work, imaging, etc, etc, that we've gone through at this point. I think that's a it's a very important conversation to start having.
Deepak Ravindran: Absolutely, absolutely, Rupy. I think it's a very good point. I'd forgotten about that. So other, other thing that I do talk about as part of the overall anti-inflammatory is a suggestion around elimination diet. So saying that, okay, the two, three other new things that have become a problem for certain populations, again, slightly controversial understand, but intolerance to gluten, intolerance to some dairy products that can evolve over time. People can have no problems with milk and then suddenly become lactose intolerant because something has changed in the way the industrial mechanism that produces it has come along. And then of course, the third part is, I think dairy I mentioned, gluten, and then probably there's a third thing that I do now I'm just completely gone. That's all right. So I do mention that, look, can we look at an elimination diet to say, well, can you have a six-week break of one of these? And this is where I realize actually saying it is easy, very difficult to do it without people needing some support. So I do specifically use either a health coach or a nutritionist to have that kind of understanding, you know, are you ready to eliminate dairy for six weeks and then reintroduce it? Are you ready to eliminate sugar for six weeks and reintroduce it? Are you ready to eliminate gluten and then reintroduce it? And how long can you go? And I think all of this needs a little bit of coaching to do it. I think going cold turkey is quite challenging for a lot of people. And if their psychosocial circumstances are not in the optimal space, then these kind of elimination diets are challenging. And in certain cases, and I think you're right in how you mentioned, it's better to probably test for these things, do some kind of allergy testing, and I know that my nutritionist colleague does those bits to decide if there is actually a more targeted way of stopping something or coming up with elimination altogether.
Dr Rupy: Yeah, absolutely. And I think, you know, elimination diets, they get a bit of a bad rep because people tend to do them solo. And, you know, there could be FODMAPs, gluten, dairy, sugar, certain other additives, and know histamines are getting quite popular, but that's can be that can be quite broad as well. Um, and testing as well. I mean, if you're going to go down the testing route, I always advise people to go and do it with someone because it's quite easy to fall into that restrictive pattern where you start restricting everything and you deprive your microbiota of all these different fibers that you require and certain foods that have the anti-inflammatory property. Um, and uh, you know, I I've done a couple of tests myself, uh, just like some of these direct to consumer tests. I don't know if you've tried them yourself, but I'm apparently allergic to everything. I'm allergic to berries, I'm allergic to grains, I'm allergic to everything. I'm like, if I was an individual and I didn't have the foresight or the understanding of how these tests are actually done, then I I could fall into that sort of unhealthy pattern. Um, whilst at the same time appreciating that these kind of intolerance tests are really useful for for people, particularly those who have a condition or or experiencing pain.
Deepak Ravindran: I agree. I think with my work in long COVID, when I sort of was running the long COVID clinic, that's when I really understood this thing of, you know, the histamine that you said, lots of patients are coming and saying, well, what about the low histamine diet? And I had some opportunity to read up about it, and I thought, wow, that is a restrictive diet and a half. It was, it just eliminates everything. And I actually told patients, look, please don't go for that. I think even the national organizations were saying, yep, not to be recommended. And I said, look, if you're going to, but patients would read up about it on on social media, and somebody in the US is doing it, and they'll say, well, I'm going to try it. And I actually tell them, look, I can't recommend it right now. I don't know enough about it. Just be or maybe even take some consultation with a nutritionist because that is one of the most restrictive diets. I think another one that's getting very popular now in in mental health and even in pain, they are looking at it is ketogenic diet, which is again sort of an extreme form of low carb diet that's coming through. All very interesting and potentially very exciting because you're coming up finally with something for mental health that's possibly, you know, doable. But even the people who are leading the research on it say how restrictive it is, how it has to be done with support and coaching and someone who knows what's doing and what to expect as the side effects or the problems. So I think a lot of these diets, we must now think of them as immunomodulators. And if they are immunomodulators, we need to exercise due precaution like the way we do with other immune related drugs that we talk about and prescribe.
Dr Rupy: That's a really good way of framing it, I think, you know, thinking about diet and changes to diet as immunomodulators because if they are impacting our gut microbiota, they are having a demonstrable impact on the vagus nerve and the microglia, you know, it's it's an important framing for people to understand just how powerful food can be. You know, your diet is an incredible lever, an incredible mover for for change. You've transitioned recently from secondary to primary care. You're really, you are going upstream. You know, you're getting to the root of where people's journeys are and and trying to get them as early as possible because from our discussions, you know, when you see them in hospital, most likely they've been through so many different clinics, they've seen so many different individuals that in a lot of ways they've kind of lost hope and they've lost that confidence. And you you really want to try and and tackle that as early as possible. I'd love you to to give us an idea as to what your new role is now in in primary care and and and what the experience has been thus far.
Deepak Ravindran: God, it's an exciting change in direction and career, Rupy, and uh, so there's as much excitement as nervousness as well. And uh, you're absolutely right. It was an opportunity for me to go upstream. And the realization is twofold. One was that in secondary care, I'm seeing patients at much further down their pain journey when they've heard a lot of misinformation or outdated information about structure and injury and hopelessness and irreversibility that when I then bring along the message that recovery is possible, that there is hope, that there is possibility of reduction in pain, the percentage of people who are ready to buy into that belief and and change and try all these integrative whole, you know, nutrition or sleep or pain management approaches is quite less. And I think that is in a way reflected in the research wherein when you look at the Cochrane meta-analysis for pain management programs, how effective are they? Well, even those kind of big evidence-based studies have said that it doesn't reduce pain. It helps in only about a third of patients. So more than two-thirds of patients aren't helped. And what they learn in a pain management program doesn't last for more than a few months. And that really works out in clinical practice as well, wherein a patient's typical journey would be two to five years before they turn up to a pain clinic. They might try a medicine or an injection, and then finally they would see a physio or a psychologist for a pain management program. They would get the benefit from doing the program, six or eight-week program, they would do that program, but then five to six months after being discharged from the pain program, they get a flare up, they've forgotten how to manage it, they are very worried and anxious, and nobody's there in primary care to help them, to address them, to support them through that space, and then they get referred back into secondary care, and then that starts the journey again of waiting. Something has to give because secondary care can't sustain this way. The staffing there doesn't allow it. And I was realizing and probably feeling that we need to do something about turning the tap off at the top, so upstream. But it's also important to have a kind of wrap around service so that the good that we do for the patient in secondary care isn't lost when they go back into the primary care setting. And in some ways, my rationale was that we've just built a lot of expertise but stacked it all in secondary care. When you look at a condition like diabetes as a long-term condition, yes, you do have your endocrine clinics and a diabetes consultant, but every GP is comfortable about looking after diabetes patients. There's a diabetes nurse specialist in every practice. There are people comfortable with managing diabetes and having a lot of non-drug-based options for diabetes management before even coming on to the drugs and any other options. But when it comes to pain, we know the drugs aren't that effective, but primary care doesn't feel ready or sometimes confident enough to look after a pain patient. There are a variety of information related challenges, there's skill-based challenges, there's knowledge-based challenges. And I thought, well, one option for me would be to say, can I help in some way changing that dynamic and working with primary care to say, how can we improve the confidence and the skill and the knowledge of our primary care colleagues so that A, we could help patients earlier in their journey, going upstream and when they have their first episode of back pain or first few months of having chronic pain due to a variety of vulnerabilities like we discussed, we can put in those measures of support much earlier in their journey. But then for the people who do come out from secondary care, they can come back into a system that's more confident and comfortable in looking after them, and the gains they have made in the secondary care can be maintained with peer support, with accountability, with coaching, with groups, with councils or whatever community-based assets that can be built, enhanced, and maintained. And when I got this opportunity with a very progressive primary care network in my local area, I didn't have to hesitate. I thought, well, here's a chance for me to walk the walk after talking the talk. And I really want to say, well, you know, how can I make a difference? How can I help in change? And I thought with our new government promoting prevention, thinking about we need to do more of moving people upstream and trying to prevent long-term conditions or at least mitigate the impact of long-term conditions, pain is a long-term condition. Pain affects, I think the, I was preparing some data for a presentation in the next few weeks, and right now, pain is responsible, especially musculoskeletal condition pain, which is pain due to arthritis, rheumatoid arthritis. It's accountable for almost 5 billion pounds of NHS spend per annum. It's accountable for almost 20.8 million work days lost. It's the second most common cause of sickness and loss of job and productivity in our economy as it stands. And it is the third most common reason for the visits to any kind of primary or secondary care setting. So we do need to do something about it that is system-wide, rather than stacking all the expertise in one corner, which is relatively inaccessible, not well-resourced, and not well-supported.
Dr Rupy: Yeah, I I I completely agree, and I just think those numbers are staggering for for people listening to this. As a GP, I think it's easy to understand those numbers. You know, a lot of what we see is pain and chronic pain issues. And you know, I'm just as we close this discussion, apart from recommending your book, which I recommend to to everyone, the pain-free mindset, you know, if there is someone listening to this who perhaps suffers from one of those conditions we were talking about, IBS, migraine, pelvic pain, and you know, they say to themselves, well, I'm of a regular normal weight, I've, you know, I generally eat well. I'm not really getting anywhere with my primary physician. What what do you think people should think about first, perhaps? How do they personalize this to their own, everything that we've just talked about today? How do they, how do they take on board some of this information? How do you tend to encourage people to take that first step?
Deepak Ravindran: I think a lot of what I'm sort of doing now, and part of it comes from this understanding of what is it that we mean when we call about behavior change? When we think about why somebody would be ready to make a change in the way they live their life. And I've realized that, and this comes from sideways from the work that all these big marketing companies, including Google have done, is they're kind of said that for someone to change their mind or even consider change, they need to hear information anywhere on an average between 7 to 20 times. If they don't hear that information, and they might need to hear that information in different ways, you know, whether it's audio, video, their cousins, their third cousin, second relative, someone needs to be giving that kind of information to them in multiple formats for them to consider making a change. And so a lot of work that I've been doing, whether it's the talks that I do, whether it's the social media presence, whether it's coming and talking to you now, is in about saying, well, how many different ways can I say the same message that hope is there, that you can recover from many kinds of pain if we can have an integrative lifestyle-based approach placed for every person, and then have certain more specific criteria, whether it's interventions or injections or surgery or drugs for certain people. As a foundation, how can we get that message to be commonplace? And therefore, a lot of times for people listening to this who want to say, I've got IBS, I've tried all that, the first thing is that hope needs to be there. One, are you ready to believe that there is still a way forward? And that if what you've tried up to now hasn't been successful, then is it because you've done just one at a time and just not paid attention to the other pieces of the puzzle? Or is it because you've done two, three things, but there have been other contemporaneous issues to your nervous and immune system so that it did not feel ready and protected to calm down. And it might be that we need to look at this whole picture and to take a more holistic approach to saying how can we do three, four things if possible? And how can, and I think this is where I really believe that measures like coaching or whether that's a group-based way of working, group consultations, whether that is some kind of peer support or accountability to be built in, those are very powerful ways, I think, in engaging that change, people to feel they're starting to notice that change. So if they have done it two years ago and they found some difference and they stopped it, did they stop it because they weren't getting enough motivation and encouragement to continue with it to stay the course for a few weeks or three, four months till new nerve circuits formed and a habit was established? Did they stop it before the habit phase happened? And the research now establishes that if you can create an ecosystem where what has been tried for a few weeks becomes a habit. And the research now says that for something to become a habit, the average time is 67 to 70 days, which kind of explains why everybody tries a 12-week thing. The earliest is around two to three weeks, which is why you have got these 21-day books coming out or the 30-day books coming out. But the longest it can take is 255 to 280 days. That is almost what the time around nine months. So how can we create an ecosystem that potentially supports someone for six to nine months so that what they have started for a few weeks can become a habit, can become a new nerve circuit that is sustainable, self-maintained, and is less prone to being broken down.
Dr Rupy: Absolutely.
Deepak Ravindran: And I think that is what we need to create as a system. How do we provide the funding for it to be able to say on the NHS, do we do it? Certainly, if there is a will in terms of getting community engagement, I have this term which I picked up from a book that came out, asset-based community development. So you know, can we map what's there in the community? Can we find out what assets are required and how do we build up what we don't have? How do we enhance what we already have? And how can we connect these dots so that you can create a template that will provide this duration of support for someone, for a broad set of population to make the change. Yes, there will always be the early adopters who will sort themselves in three, four weeks, will have a huge amount of family support, maybe will not have vulnerabilities, will be super good at, you know, making change. They come all warmed up. But then we've got to understand that a lot of our patients are probably on the other end of the curve where they have seen a variety of social circumstances that haven't shown them that recovery is possible. And for that group of people, we need a system that recognizes that and puts in the ecosystem for those people also to say, you know what, I can change, recovery is possible, and if I do this, there are people to support me to kind of egg me on till I get that as routine.
Dr Rupy: Yeah, you know what? And this is why I love the medium of podcasting because we've talked to, you know, about about pain for two hours or something like two hours. I don't even know, but like, you can't have this nuanced discussion with an individual in the confines of an NHS GP appointment. And I think what you said there about cohort-based interventions, group-based interventions, a community around this is so, so important and going upstream as much as possible. Um, so, you know, more conversations like this, more information out there like this, just like you're doing within your field of of pain specialty, but also within primary care now, is exactly what needs to happen. And I'm conscious that you need to pick up your daughter and take her to martial arts. So we'll end the conversation there, even though I've got tons more questions for you. But Deepak, it's a pleasure to to have you on the pod. I I want to promote your work as much as possible. People should 100% get your book. I often gift it to to GPs who are at the coal face of this. You know more about that than me currently. So, you know, it's it's um, yeah, it's it's just a pleasure to have someone like you really banging the drum for this much needed movement.
Deepak Ravindran: Likewise, Rupy, thank you for all the work that you do and thank you for having me and it's wonderful to finally do this face to face. It's really nice. Last time we did about two, three years ago was all in the time of COVID and online. So it's lovely to come and meet your team and and do this all face to face.
Dr Rupy: Pleasure is mine.
