#312 Professor Shares 6 Longevity Nutrients to Preserve Your Strength and Help You Age Better | Professor Ailsa Welch

Dr Rupy: Professor, what are the six nutrients that matter most for aging?

Professor Elsa Welsh: Well, I might say there are more than a few, more than six, but to be honest, we all know that protein, calcium and vitamin D are really important. And we also know we need iron because of anaemia. But more recently I've been doing work on magnesium and vitamin C, carotenes that we find in in fruits and vegetables. And also we need to be thinking about a lot more about fibre than we used to, we've come back round to that, and also fatty acids as well. It's important the types of fat you eat.

Dr Rupy: Okay, so there's quite a few more than just six.

Professor Elsa Welsh: And I would say also, yes, and there's also thinking about alcohol as well.

Dr Rupy: Yeah, so things that we need to remove, I guess. Let's let's dive into one of those. Pick your favourite one, you know, magnesium, vitamin C, one that you think perhaps gets less airtime than it than it should.

Professor Elsa Welsh: Yeah, well, I've been doing a lot of work on where why we get sarcopenia and how nutrition influences that. And sarcopenia is where you start to lose muscle as you age, both the amount of muscle you have and then how strong you are. So those two combinations then lead to a number of things and they lead to also osteoporosis, which is where your bones get thin and and then you end up with fractures and so on, particularly the painful ones that you get that are called low impact fractures. And so, yeah, I've been working with magnesium in particular because it's one of those nutrients that seems to come out particularly in my studies where we do work on big populations. So we look at a population and see what the differences are between people and then work out what it might be. And magnesium is sort of standing out really very strongly, particularly in relation to, well actually it's in relation to, I've showed it in relation to blood pressure and cholesterol levels, but much more in terms of muscle and bone and related to how whether you have fractures or not, well, the number of fractures you're likely to have, how much how your the strength and function of your muscles, and also how much how much actual muscle you have in your body. Okay. So that seems to be in some way protective and I think there's a number of ways it works. Would you like to tell me about those?

Dr Rupy: Yeah, I was going to say, like, if people have probably heard magnesium in the context of supplementation, you know, online, everyone's telling people to take certain magnesium supplements. If you were to describe why we need magnesium more broadly to an individual, how would you describe what magnesium is and perhaps where you naturally get it? And then we can talk a bit about the importance to bone and muscle health.

Professor Elsa Welsh: Yeah, so magnesium is found in lots of foods actually. So it's found in lots of foods such as green vegetables. And interestingly, the reason vegetables are green, it's got this, it's got the chlorophyll, it's actually the centre of that is magnesium, in fact. So like, you know, our blood cells are red, that's got iron in them. So plants have magnesium. So that's why you get a lot of magnesium for those foods. Also, things like things that have a lot of fibre in them, whole grains and so on, they're good sources of magnesium as well. And then you get some in some of the animal foods as well. So but there's a lot in the plant kingdom that's actually useful for magnesium. And the other thing is with magnesium, it's also, the reason it's important is because there are at least 300 enzymes and different processes in the body that need magnesium.

Dr Rupy: 300?

Professor Elsa Welsh: 300, yes. Over 300. And actually I don't think we know all that we need to know yet. So I think really it's it's interesting in that respect.

Dr Rupy: Yeah, it's really interesting that I don't think people realise just how important magnesium is to all these different pathways in the body. And it's interesting that you say that we probably haven't fully investigated all those different pathways that you know, are the reason why magnesium is so important.

Professor Elsa Welsh: And one thing we need is is to have a good amount of magnesium in the blood. So we don't want it too high or too low. And the reason it tends to stay very steady and the body keeps it steady is because it does affect all these enzymes. So it works really hard, these processes in the body, the body works really hard to maintain it at the right level. And so, you know, it's excreted, it's absorbed through the intestines in your gut, but then it's also excreted through the in the urine as well. So it's a real balance. And then of course, we need magnesium for bones and for muscle. It's it's and I think people have realised that magnesium is less, they haven't really thought about magnesium so much in terms of bone. They always thought about calcium, but magnesium is part of the structure of bone as well.

Dr Rupy: You know, as you're saying that, as a GP, I worked in the NHS for many years. The first thing that's drilled into my my head is calcium, and then vitamin D, and then probably protein. I don't think I was really thinking about magnesium back then.

Professor Elsa Welsh: No, not surprised. A lot of people haven't been really. I just realised there was a lack of information about those nutrients, particularly I was interested in at that point in looking at muscle because people hadn't really looked much at all at micronutrients and muscle really. I mean they'd looked at vitamin, well actually vitamin D even since I've been working on muscle, vitamin D's only sort of, I would say become in the last 10 years become recognised as really important for muscle. But people just haven't really thought about it so much. But you also need enough vitamin D to absorb your magnesium and your calcium anyway. So that's very important. They all work together.

Dr Rupy: Okay, so it's not like these are isolated micronutrients. They work in harmony to keep the body balanced.

Professor Elsa Welsh: And actually nearly all the micronutrients do that really. It's the same as calcium, you know, calcium similar to magnesium, at least 300 kind of processes and calcium is essential for those anyway. So you know, you need those, you need a decent level of calcium in the blood too. And again, you know, clinically you would have known what would happen if you have low or high calcium. It gives you all sorts of issues in your body, doesn't it?

Dr Rupy: Absolutely. And in terms of, so just for the listener, let's drill down into what we mean by magnesium helping with these different pathways. Is magnesium used as a cofactor, as an enzyme essentially, or is it used in a different way?

Professor Elsa Welsh: Well, I mean for bone and muscle, it's well certainly for bone it's part of the structure, but it's also used as a coenzyme. It's used in it's used in a number of processes. It's also involved in mitochondrial function. So mitochondria are these little tiny parts in your in the cells that are in your body that actually release energy. So they're it's needed so that you generate energy really in these tiny mitochondria. So and we know that from some work that a colleague of mine has been doing. So it's kind of really interesting because some of these things we didn't really know so much about until recently.

Dr Rupy: And you mentioned magnesium level in the blood is super important and the body works really hard to keep that steady, but we find magnesium in other places in our in our urine as well as in the serum. How what is the best way to measure magnesium?

Professor Elsa Welsh: Complicated because you can measure it in blood, but as I said, the body's trying so hard, like with calcium to keep it so stable in the blood, it really then the rest of the body suffers in a way. So that's when the bones suffer because you know, it will be released from the bones to actually make sure there's enough magnesium in the blood. If you have, I mean in terms of excreting in the urine, there's a lot of things that affect that as well. Do you want me to talk about that too?

Dr Rupy: Yeah, yeah, please, yeah.

Professor Elsa Welsh: So, so some of the things that people don't realise is that say when they have or drinking a lot of alcohol, lots of pints a night, you know, lots of spirits, bottle of wine, that sort of thing. That impacts on how much magnesium you goes out in your urine and it does leave your blood lower and to get that blood back to the way it should it wants to be, basically then it releases it from bones and probably also from from the from the muscles as well. But also other things that affect that, some of the drugs. So there's one called omeprazole which people use for you know, when you've got indigestion all the time. So that's one thing that makes you excrete more, lose more magnesium as well. And then there's some, so that's one of the proton pump inhibitors as they say. There's some diuretics as well, particular sorts, not all of them that make you lose more through your kidneys. So you're losing magnesium partly because in in stools, you know, when you go to the toilet, but also you're losing it in your urine as well.

Dr Rupy: Gotcha. Okay. So a measurement of magnesium that is quote unquote normal in the blood level doesn't necessarily mean that you're not getting, you're getting enough magnesium.

Professor Elsa Welsh: Yeah, and that's the trouble with measuring magnesium. You can measure it better in red blood cells. Okay. And it's a little bit more precise than if you measure it in plasma, but it's it's still not easy. Having said that, clinically, if somebody's at risk and you know, it can either be much higher or much lower than you would want than you would normally be. And then if you that tends to happen, say it would be higher if your kidneys failed. So basically as we're getting older, any age from about 30, we start to decline sadly. And so your kidneys start to function not so well. And once your kidneys are not working so well, particularly if you go into what's called renal failure or kidney failure, that's when magnesium levels will be much higher in the blood and that's an indication that's not so good for you. Right. At the other end also it can be much lower and that's probably a combination of really not having absorbed very much and also having other problems that's usually a sign of some kind of clinical problem as well.

Dr Rupy: Gotcha. And so it sounds as if the bone is an area where we store magnesium that we can utilise if we're passing too much through urine, through alcohol or certain medications. Are there any other stores of magnesium?

Professor Elsa Welsh: They're in the blood as well. It's in the blood. And it will be in other tissues, but thinking about and muscle clearly, muscle is one of the biggest stores as well.

Dr Rupy: Okay.

Professor Elsa Welsh: But as to brain, I don't know, but I have no idea.

Dr Rupy: Okay.

Professor Elsa Welsh: Brain's more of a fatty tissue, so it's slightly less likely.

Dr Rupy: Gotcha. Okay. So in terms of the amount of magnesium we should be consuming to preserve our our muscle, preserve our bones. Do we have an idea from perhaps some of the work you've done with with Epic as as to what the amount is?

Professor Elsa Welsh: Yeah, I mean there are some guidelines, but again, they're kind of they're not quite so hard set as say the guidelines that we have for calcium and vitamin D. It's been less studied. But most people probably about 200 to 300 milligrams a day is reasonable depending whether you're a man or a woman. But a lot of people don't reach that throughout Europe, most people don't. And that gets worse as you get older, as people get older because partly because they may not be eating the foods that supply as much magnesium. So your green veg.

Dr Rupy: So no greens, yeah.

Professor Elsa Welsh: No greens and they're harder to eat and chew and people don't feel like that. So and also probably eating less meat because that's a reasonable source. And the reason why, you know, it's a reasonable, magnesium is important for muscle, but you can see it because it's actually found in muscle when you eat animal products too.

Dr Rupy: Do vegans and vegetarians tend to be more at risk of magnesium deficiency for that reason?

Professor Elsa Welsh: Not necessarily because they as a rule, well, if a vegetarian or vegan is eating a a very plant, a great plant-based diet, you know, that's actually made of lots of vegetables, cereal foods, you know, so sort of wholemeal breads, those sorts of things, they're probably not that much at risk, but they'd need to be cautious about their vitamin D levels.

Dr Rupy: Okay.

Professor Elsa Welsh: And I think anyway, I would say for vegan or vegetarian on the whole, you want to be taking vitamin D supplement.

Dr Rupy: Gotcha.

Professor Elsa Welsh: Because although calcium might be lower, your intake might be lower, the whole point with vitamin D is that you actually it with your bones and so on is that you need vitamin D to absorb these calcium and magnesium.

Dr Rupy: Gotcha.

Professor Elsa Welsh: And if you haven't got enough, then you're not going to absorb it properly. I mean there is a balance anyway because calcium is varies depending on your needs. So the body only absorbs as much as you need really, which is why it's only a percentage absorbed and that does vary. But even so people still end up with difficulty with osteoporosis and so on.

Dr Rupy: Yeah. With supplementation, which is like a quick fix and a lot of people are being marketed magnesium supplements. You might have seen them, magnesium bisglycinate, magnesium threonate, magnesium citrate. Is it just as simple as taking a magnesium supplement to make sure that your bones are healthy and your muscles are working?

Professor Elsa Welsh: Well, first you need to make sure your vitamin D was okay.

Dr Rupy: Okay.

Professor Elsa Welsh: And of course you can you can get vitamin D from sun depending on the time of year in this country. It's only really between about May and October. And also you've got to be careful not to burn yourself, but you can get vitamin D from that. But chances are you you are likely to need a supplement or you know, a small amount of vitamin D anyway. In terms of magnesium?

Dr Rupy: Magnesium. Yeah.

Professor Elsa Welsh: I think the difficulty with some of those is that actually you could end up with maybe too much magnesium.

Dr Rupy: Really?

Professor Elsa Welsh: And actually some of them do cause you to have an upset stomach. And that's quite usual depending, I mean the ones you were mentioning, the threonate, glycinate and so on, they're not such a problem. But some of the kind of cheaper ones are, they do cause.

Dr Rupy: Which ones are like the oxide, like magnesium oxide?

Professor Elsa Welsh: Yeah, yeah, the kind of classic ones that are much cheaper to make.

Dr Rupy: Yeah, yeah.

Professor Elsa Welsh: Interesting. Is there anything wrong apart from over supplementing and potentially putting yourself at a high level of blood magnesium? Is there anything wrong with taking magnesium supplement just in case?

Professor Elsa Welsh: I guess not, so long as you know your kidneys are okay.

Dr Rupy: Okay.

Professor Elsa Welsh: Yeah. Um, yes, it's fine, but my kind of feeling is on the whole you're best off having a a diet that helps you get the right amounts of magnesium.

Dr Rupy: Yeah.

Professor Elsa Welsh: But if you can't do that, then yes, it's possible. Yeah.

Dr Rupy: You did some work with you do some work with with Epic. Um, is there are there clear sort of associations with the lowest level of magnesium intake versus the highest level of magnesium intake and markers of of successful aging, like muscle strength and bone health?

Professor Elsa Welsh: Yeah, we've been I've been working on a few cohorts. There's also the Baltimore longitudinal study of aging. So we've worked with them using markers and that's in the blood. Epic and also the twin twins UK study. So you know Tim anyway, so.

Dr Rupy: Yeah, yeah, yeah.

Professor Elsa Welsh: Yeah, so we did find that actually overall, so doing with the twins was the first one we looked at more and certainly we looked at more muscle function. So we looked at leg explosive power and we also looked at grip strength and also the amount of muscle mass, which is actually technically called fat free mass because that's the bit you measure with these machines. And we found that essentially, it's just almost linear, you know, you divide it, you divide your information up into five parts as to how much magnesium you're eating and and and the and the factors we were looking at such as muscle, muscle mass and and function were very strong. And actually for leg explosive power, it was 25% higher than people at the bottom end of the the distribution of what they were eating. And that was actually after taking protein into account. So protein was sort of we adjusted for all those things in our analysis.

Dr Rupy: Really? Yeah. So it's almost like magnesium is as effective as protein or as important as protein.

Professor Elsa Welsh: Well, it seemed to me, yes, and I think going back to what we were talking about with with mechanisms, you need magnesium to do many things. And actually if you don't have enough of it, then you're not going to synthesize your protein so well. So actually one of the other people I've been working with on on this area was um, I've obviously been working on um with Epic and other studies where we're looking at magnesium. And I was at a conference in oh just before lockdown actually before COVID and there was a guy there who had a poster up and he was looking at what some of the mechanisms because we haven't really known quite how much why magnesium would be important for muscle and you know, I'd seen it, but you know, just because you see something in in a in a study cross section, it doesn't mean to say it's actually really the whole answer. And so they've been doing some work on on mice, aging mice and they'd looked at they were looking at whether if they had no intervention, whether they had a vibration therapy which would aim to kind of increase muscle, whether you gave them just magnesium or whether you gave them both. And basically then they looked at all the different ways of using all sort of fancy tools, you know, you can look at little chromatographs which show you lines and so on. And you could see that actually the mice that had both magnesium and vibration had much better muscle in their legs say, but also they were looking at some of the biochemical pathways. So when you want to stimulate muscle synthesis, there's a a particular pathway which is stimulated by something called mTOR. And that then sets off a pathway for protein synthesis. And so what they were finding was that actually the magnesium was stimulating the mTOR. So actually now we know. So having kind of seen it in in in populations then going back through to working out why it's happening is really quite nice to see that. So they they published that fairly recently as well.

Dr Rupy: That's so interesting. So you've got multiple stimuli for mTOR or mechanistic target of rapamycin. And so I I always thought of that as, okay, you've got your exercise stimulus, you have a protein or leucine stimulus. And you've also got now magnesium and I guess there are probably some other things as well that would also stimulate mTOR for muscle growth.

Professor Elsa Welsh: It hasn't been looked at so much, yeah. But actually I don't think it's just leucine that's stimulates mTOR. There's more just some more recent work coming out that some of the other minor acids also stimulate mTOR.

Dr Rupy: Really? Interesting.

Professor Elsa Welsh: So lysine is one of them, that sort of thing. So actually it may just be protein overall, but just the way that most of the research has been done was just looking at leucine.

Dr Rupy: Okay, great. All right, so get your magnesium in and two to 300 milligrams is sort of like the base, you would say for magnesium. And I mean, how are you getting your magnesium every day? Is it a personal question?

Professor Elsa Welsh: Oh yeah, I I actually eat an awful lot of green vegetables, you know, and salads and um all those things, um seeds and nuts, pumpkin seeds, those sorts of things.

Dr Rupy: Yeah.

Professor Elsa Welsh: Um,

Dr Rupy: We looked into this actually for a recent video. Um, and it's it is quite achievable to get a good dose of magnesium from fruits and vegetables, pumpkin seeds, like you said, things like kale, other cruciferous vegetables, like you can get a lot of magnesium in, but if you look at a typical diet, as I'm sure you've learned, you know, looking at thousands of people in those large cohort studies, most people just don't get those kind of ingredients in their diet every single day, right?

Professor Elsa Welsh: No. And and I mean there is, you know, there's magnesium say in whole grains and wholemeal bread and so on. But even now I was just looking at the most recent publication of the government survey. So there's a big survey they do um and publish the details every other year more or less, but and it tracks the nutritional health of the nation essentially. And you know, they were looking at that and and hardly anybody reaches the 30 grams a day guideline for fibre. So you know, that's something that's important in that respect. But but also, you know, we're going back to where we we always knew fibre was important. It's been slightly out of fashion, coming back in because of the microbiome, which clearly is always going to be relevant.

Dr Rupy: Absolutely. Okay. Have we done magnesium, do you reckon?

Professor Elsa Welsh: I don't know. I could probably talk more, but I think probably I think that's probably magnesium for now.

Dr Rupy: Okay, cool. All right, magnesium. I think we're we're big fans of magnesium now and you don't necessarily need to supplement. If you were to supplement, are there particular supplements that you would say you can try or would you just say avoid the cheap ones?

Professor Elsa Welsh: I would say, I mean have a, yeah, what I would say is if you're going to start with the cheaper ones, keep the dose low. Uh-huh. You know, just have say if it's two tablets a day, start with one or a half a tablet or something, see how it goes. Okay. Um, because some people are really sensitive and some aren't. Because if you find the cheaper ones work for you, then that's fine.

Dr Rupy: Okay. Great. And making sure that your vitamin D level is adequate as well.

Professor Elsa Welsh: Yeah. I mean, how you know that unless you get tested is another thing.

Dr Rupy: Yeah, yeah. I think it has to be testing unless you've got like clinical signs of vitamin D deficiency, which can be vague as well. Um, okay, great. Let's can I choose one?

Professor Elsa Welsh: Okay.

Dr Rupy: Vitamin C. I I I think vitamin C is super important because I think when people think about healthy aging, they think about protein, they think about vitamin D and calcium, like you said at the start, naturally. I don't think many people think about vitamin C through the lens of aging. Um, so so yeah, let's dive into that. Why is that so important?

Professor Elsa Welsh: Okay, right. Well, that also is very important for a number of different factors. But for I suppose particularly for muscle and bones, it's relevant for um because collagen, which is the protein that's the structure of, you know, you have this part of your skin, it's it's a structural protein that keeps your bones together and that's what, you know, where the magnesium lodges and so on. Um, it's it's also in in muscles too. Um, and we need collagen for just about everything. Well, vitamin C is a cofactor in formation of collagen. That's the first thing. Um, it's also for um for um muscle, it's it's needed for um when you when we're talking about contracting muscles, um there's a again a compound, it's called carnitine, which helps you contract your muscles. So the vitamin C helps you um essentially that that helps towards contraction of muscles as well. And then less, we don't really know this and this is some work I'm doing now, um is that we know that mitochondria need vitamin C. Um and nobody's really looked to see how that impacts on if you were if you somebody has a low vitamin C when you give them a supplement, how that how the how the mitochondria would react. So um there's other factors. I'm just thinking of other things that that it's involved in, but those are the kind of key things I would say.

Dr Rupy: Okay. Yeah.

Professor Elsa Welsh: Any any skin structure. And of course, you know, you know if you've got if you get scurvy, which is low, low enough vitamin C to be showing um in your system, you feel very tired, you feel irritable. Um and you know, you feel um and also you can end up with bleeding gums and those are all signs that actually it's affecting your collagen. And one thing I do remember, I just sorry, I do kind of tend to go a bit wider.

Dr Rupy: No, we're going to tangent.

Professor Elsa Welsh: But we went to the Mary Rose a while back. And um obviously I've been interested in bone and and vitamin C and thinking about why it was there. And there was a bone from one of the um young sailors that was you know, in in um in a in a case and basically you could see the lesions from scurvy on this bone.

Dr Rupy: On the bone?

Professor Elsa Welsh: On the bone. So it was actually causing holes in the bone essentially, you know, well indentations shall we say. Yeah. So I did actually have it to show the my medical students actually at one point because I think it's it's it's useful to see a tangible reason why a nutrient has an effect. Because we all talk about it, you know, and then it's just kind of, oh, you go down, maybe go and eat somewhere and don't think about it. It's kind of useful. I think sometimes it's useful for people to know why these things work.

Dr Rupy: Yeah, yeah.

Professor Elsa Welsh: You don't have to, but it's just quite nice to know because it it makes it um more understandable. It's not just, oh, you should have more vitamin C, you know, there's a reason for it.

Dr Rupy: Oh, totally. I mean, like you're you're speaking to a really willing audience right now who want to know about vitamin C and the relationship to collagen, mitochondrial health, muscle health, bone health. I don't think people naturally make that association, perhaps with with collagen, but most people think about vitamin C from the perspective of inflammation, oxidative stress, which is obviously very, very important, but also skin health and you know, vibrant glowing cheeks and all the rest of it. Um let's let's dive into the relationship with vitamin C and and collagen in particular because I think most people might think, okay, collagen, let me go and get a collagen supplement. Let me make sure I've got enough protein. But it's it's sort of the combination of having enough amino acids and vitamin C.

Professor Elsa Welsh: Yeah. Yeah, and I I think unless you've got those two things together, um you know, your body isn't going to work. I'm not sure, to be honest, I haven't looked at collagen supplements lately. They may be useful, but I and and there is talk obviously about them being useful for muscle function and so on.

Dr Rupy: Sure, yeah.

Professor Elsa Welsh: But I don't know that actually when it comes to anyone's compared a study where you gave someone some meat, meat, beef or something with collagen supplements and see whether there's a difference. Because essentially most of the collagen supplements are coming from um boiled down either fish or meat or something. You can get plant-based ones too, but you know, so I I don't actually know and it's still got to get through your gut into the system, be carried around and so on. So I don't know really.

Dr Rupy: Yeah, I've always found that perplexing as well because you're essentially giving your body free amino acids that are purified from bone or fish skin or whatever it might be. And for some reason it magically repurposes as collagen in your joints and your skin, etc. But there does appear to be something in the literature that shows a a positive endpoint because I used to be quite dismissive of collagen supplements, but now hydrolyzed collagen appears to potentially have some benefits. Uh and I'm interested from a joint health perspective. Yeah. Um I think that could be quite interesting. Um but vitamin C, so vitamin C is a cofactor in the collagen production process. So when you've got enough protein in your diet and you've got enough vitamin C, it appears to enhance that mechanism, is that right?

Professor Elsa Welsh: I think so and that's why, you know, the collagen's breaking down in your body, it's not functioning. That's why when you end up with scurvy, you've got those problems because it's just not working. And actually thinking about it, it's probably also important for red blood cells because there's a but um I haven't think but because of course they they have vitamin C in them as well. So you can imagine. So it's it's important for and as you say, you know, the whole knowledge about potential antioxidant activity, anti-inflammatory activity, which is when you you know, these these are um factors that build up as you get older. You know, this is the C reactive protein, which is the um which is a measure of inflammation. It's it's a protein produced in the liver. And actually recently I was I should just recently published some work where we'd looked at vitamin C in blood in people in Epic, the Epic study, and also um magnesium in blood and then looked at the C reactive protein and basically, you know, the more of those things you have in the blood, the less the CRP. So you know, straightforward relationship really.

Dr Rupy: Yeah. I guess so the vitamin C, maybe do you mind talking a little bit about what Epic is? I know I've mentioned it, but perhaps some people haven't heard of what what the Epic is.

Professor Elsa Welsh: Yeah, sure, yeah. I mean this was a large study that was started in the early 1990s and there were two sections, two centres in the UK, Epic Norfolk and Epic Oxford, and then there were centres all around the the um around Europe. So in the end we ended up with 10 all the way from Umeå in the north of Sweden right down to the south, basically in Spain. And um and it was set up and there were east and west varieties too. And it was really set up originally because um it was run run from the International Agency for Research on Cancer, IARC in Lyon. And it was set up originally because it was clear there were differences in in rates of cancer across different countries. And you know, that there had been a lot of work that showed there was different rates of cancer when people migrated to say from one country to another, say from Japan to Hawaii and so on. Um and also you could see that if you looked at the map of Europe, you've got all these different countries and cancer rates changed on the border, which is very weird because it wasn't just about reporting. And so um Nick Day, who was kind of he was then at um over in in um in at IARC, he he proposed this study and we run it with Elio Riboli, who's at Imperial now. And um you know, basically worked out that we basically were going to study everybody and then also collect blood so that we could analyze it later because at that point nobody'd ever really done that. They'd asked lots of questionnaires and so on, lots of so we diet was a key thing and there were lots of questionnaires and lots of methods that we had to put together. Um and then so so we were looking at that and then then in the in the UK, we also particularly in the Epic Norfolk study, which is obviously you can see it was it was done in Norfolk and run from Cambridge. And we we also looked at other factors that were important for aging conditions so such as diabetes and cardiovascular disease and so on. So we measured cholesterol, HBA1C and so on and lots of those other things which you look at routinely now, but weren't measured so so frequently then. So then we were able to look at a lot more outcomes as we call it, different types of diseases and conditions than just say for cancer. So basically, you know, it's been it's been shown overall, you know, headline is that a much more healthy diet is better for um preventing cancer. This is at the international level. Yeah. You know, and and it makes some sense for that. I guess that's quite hard to translate to somebody who wants to sit at home and think, well, how am I, you know, how's that going to help? But um but that's overall I would say.

Dr Rupy: Well, I guess it gives you the characteristics of a diet that is preventative, you know, it's a true preventative medicine in itself. And and some of the insights that you've already shared today in terms of where you get your magnesium from, where you get your vitamin C from, which we're going to go into in a second. You know, this is stuff that you can actually give tangible advice to to folks with tangible instructions to folks. So yeah. And it's definitely been impactful for me. I mean, I I've read a whole bunch of the papers and it's been a an really huge resource for so many people. Um let's talk a little bit about vitamin C in the context of inflammation and oxidation. So as we age, inflammation levels appear to creep up. And I guess, you know, there's lots of different hallmarks of aging. What what why at a very sort of, I know it's a very big question, but why at a broad level does that actually occur? And at what level would you see inflammation levels creeping up?

Professor Elsa Welsh: Yeah, I guess I mean some of it's basically some of it may be down to diet actually and some of it's down to other factors. But um inflammation starts, basically, you know, we get inflammation when we get an infection, get COVID or cold or something. You're very lucky to have your inflammation because that that kicks in, you know, those inflammatory factors and it will deal with the infection and so on. So we need that. And that's that's a very high rise in in in a particular of the different range of inflammatory factors and then it dampens down. But with aging, it does seem to be creeping up. Some of it is probably down to um to be honest, when people have more um body fat and and they get more overweight, then it builds up for that. That's for sure. Um and actually there is an interaction say with vitamin C and blood and um the amount of fat, it does make a difference. If you actually have more vitamin C, your say for instance your C reactive protein we were talking about, that will be lower. So um and then what that does is is actually essentially inflammation say in your bones, you've got these um these cells that build bone called the osteoblasts and the cells that break it down called the osteoclasts. That's how you can remember them. One is building and the other isn't. And actually inflammation intervenes in that and makes a big difference to actually how those operate. So um there's a lot of factors that are really changing um as you get older. And what I I suppose what I don't know entirely is say if it is just age dependent or whether it is about our body composition and other things and our diet. Because what we do see now is that younger people have higher C reactive protein, they have higher cholesterol levels and so on, many of them do. And they're all indicators of what would normally have been seen just aging, but they're just aging sooner if you see what I mean.

Dr Rupy: Do you think we are aging sooner?

Professor Elsa Welsh: That I can't say for sure, but I do wonder because I think when you see um there are certain diseases, well like type two diabetes is occurring much earlier in in in younger people now and it only ever used to be seen when people were much older. But now that that is um occurring, isn't there? So MODY, maturity onset diabetes of the young. And some of that is I think, I mean if I can divert onto what fat is and you know, what it's doing, um we used to think that fat was kind of inert. You know, I've been around long enough to where we just didn't really think it was just a tissue. We didn't really think too much about it. And then we began to realize it had all these inflammatory factors, had cytokines, other things coming from it, different cells, the cells were changing depending on what was going on. So basically it's a very active tissue that secretes a huge number of different compounds and don't ask me to list them all at the moment because I can't remember. But but you know, what that's doing that so that's really um and that's putting a burden on the body's systems really. So the more adipose tissue you have, it's putting a burden onto all these nicely controlled sort of little systems that we have. They're just being distorted really.

Dr Rupy: Yeah. And with that that rise in, you know, earlier diagnosis of type two diabetes. I mean we're also seeing earlier diagnosis of cancers as well. I mean it's the cause is going to be multifactorial of course, you know, you've got diet, you've got environmental pollutants, you've got a change in lifestyle, you've got reduction of vitamin D, sedentary behavior, etc. Um does that mean that we need to adjust our diet to have more things like vitamin C in uh like even more so. So we we should be consuming more vitamin C as we age. It's almost like the quantity that we require to sort of mitigate against this gradual rise of inflammation is yeah.

Professor Elsa Welsh: Yeah. Um there was just a recent paper came out um somebody called Anita Carr who's in New Zealand, she's done a lot of work on that. And you know, we've looked and my colleague few um few means as well. And that was using epic data, but they they they analyzed how much vitamin C would need to actually kind of become um to have the right amount in your blood because what we know is if you have a higher waist hip ratio, so you've got a much bigger waist, um if you if you've got a higher BMI and if you smoke, all those things um sort of tend to nuke the vitamin C in your blood, you know, essentially it's it's used up. So um and so they reckon that actually, you know, our current guidelines in the UK are quite low. Actually they are low, they're about 30, 40 milligrams a day. And and the Americans have been on 80 milligrams for a long time. But they reckon it should be at least 100 milligrams or more.

Dr Rupy: 100 milligrams, okay.

Professor Elsa Welsh: And it should go up um it should go up for every 10 kilos of extra body weight that you have as well.

Dr Rupy: Another 10 milligrams.

Professor Elsa Welsh: That's new. That's not guidelines, but actually I think it's really useful to know because I think a lot of guidelines in the past, dietary guidelines are great, you know, and they've put a lot of effort in, but they've been about um preventing deficiency rather than improving aging. And um yeah, so I think that's but but I suppose the other thing I was going to say is that if you have even if you if you were having not so much vitamin C in a way is because when you have more than you need, it just gets excreted in your kidneys through you know, go through your kidneys and it's excreted so it doesn't sit there. Obviously it goes into your white blood cells and red blood cells and so on, but it doesn't sort of um it it can't stay very high in the blood because actually that's not good for you because actually it can act as a prooxidant. So um if you're having very high levels of vitamin C and your and your kidneys aren't working properly, it's it's doing very much more harm than good. So you know, you need to restrict it to if you're going to take supplements, you really need to restrict it to um to probably I would say on a daily basis less than 500 milligrams unless you've been told that you've got scurvy or you need it for some reason.

Dr Rupy: Gotcha. Yeah. And with the it's not guidelines yet, but let's say the 100 milligrams, I'm assuming this is coming from fruits and vegetables and whole foods rather than supplemental vitamin C.

Professor Elsa Welsh: Yeah, yeah. Because supplements of vitamin C, you know, it's in grams. Like people are literally taking grams of the stuff as a supplement.

Professor Elsa Welsh: I yeah, I'm not sure I would. Firstly, well, firstly you've got the gut disturbance, you might be lucky to get away with that. You wouldn't have problems with your gut. But secondly, you can have kidney stones. And the other thing that can happen too is that when you stop taking those, you then get scurvy.

Dr Rupy: Oh, really? Because your body's adjusting to the higher amount of exogenous vitamin C.

Professor Elsa Welsh: So personally I wouldn't and and what we don't know any of us really most of the time is as we are getting older, how how well our kidneys are working. Um they're obviously declining a bit like everything declines, you know, we talked about the declines in in bone and muscle and so on. They're slow, but they and some people are much slower than others. Um but I think really you need enough um you you need to be cautious on um what what sort of items you put in your body depending on how your kidneys are working. Because if you put some of these, we'll talk too much calcium for instance, probably not so bad because it gets the gut restricts how much goes in the blood, but some of these other nutrients, they're going straight through, they're going to build up and then they could be acting as prooxidants as well.

Dr Rupy: I don't think many people realize vitamin C being or having prooxidant potential.

Professor Elsa Welsh: Yeah, there was a bit a few quite a few years ago now, but there was a lot of discussion about it because there's a guy called Joe Lunec who worked in Leicester and he was looking at these, well with cancer you get these um changes in DNA and there's one um and they're called DNA adducts that come out in your urine and you measure them in blood and that one of them is um eight hydroxyguanine and basically he'd um he'd done some studies and he found that actually it did too much vitamin C increased the levels of those um excretion of those um adducts, DNA adducts. So I mean it it's it's come and gone a little bit, but certainly most people don't know that very high doses are potentially bad for you.

Dr Rupy: So I mean, yeah, Linus Pauling was kind of very keen on it and

Professor Elsa Welsh: Yeah. And he may not have been wrong because he's very far sighted, but I think I think there's a limit to how much we should be putting in your body in terms of just what you know, with food it's always safe because it's got to be digested and absorbed and that's you know, but but actually um straightforward um large doses of a single supplement too are not always so good because I think they they do interact with each other. We're talking earlier, you know. So and it may not always be the best thing for you. It's always going to be safer with with food.

Dr Rupy: Because I always worry like with people taking especially with the rise in popularity of intravenous therapies and intravenous vitamin C is becoming quite popular. Yeah, particularly amongst people who are trying to address certain cancers or autoimmune condition. Um and there are there's a I was just in in LA recently and there's definitely a rise in in um clinics providing intravenous vitamin therapy.

Professor Elsa Welsh: Yeah, I think I think people need to look into you know where it turns into a prooxidant or not. Um you know, and there are times perhaps when a prooxidant is useful because you might be wanting to say for instance target something like a cancer that might react to that.

Dr Rupy: Sure.

Professor Elsa Welsh: But I don't think you want to be doing that on a on a regular basis.

Dr Rupy: No, no, no.

Professor Elsa Welsh: I mean the time when it may actually also work is you know, um if you are getting a cold or something like that and um you take a big dose then and doing you know, taking a big dose for two or three days isn't too bad, but doing it continuously, I think I would be wanting to avoid.

Dr Rupy: Yeah, yeah. I mean, I I must admit whenever I feel a cold coming on, I do take uh two grams of vitamin C just supplementally, but only like you said, only for a couple of days.

Professor Elsa Welsh: Yeah, I think I think that's okay. I mean it's not you know, a particular problem. Um and also if you're younger anyway, your kidneys are going to be fine pretty much. So it's it's just when you get a bit older and you don't know what they're doing.

Dr Rupy: So to use a a very crude analogy, um when you when you get older, you have a higher level of inflammation and this oxidative stress. So to mitigate that and balance that, you need a higher concentration of vitamin C that ideally you get from whole food sources. So your requirement to mop up that inflammation goes up as you age. So in an ideal world, perhaps there was dietary guidance that actually tells you, okay, you need to be eating more vitamin C rich foods as you get older. But this is something that people can start doing today. Is that right?

Professor Elsa Welsh: Yeah, yeah. And I think and also, you know, I was thinking last night about vegetables as well. We tend to forget that actually, you know, you think it's just fruits, but actually it's, you know, broccoli's got broccoli's got high amounts and a lot of the leafy vegetables do have a lot of vitamin C. Depends how you cook them afterwards, but um you know, so you can get vitamin C from lots of different sources. And um you know, it's absorbed so I think ideally that's what we want to be doing.

Dr Rupy: Where where do you get your vitamin C from?

Professor Elsa Welsh: Oh, you're going to do that again.

Dr Rupy: I'm not going to do it for every nutrient, I promise.

Professor Elsa Welsh: Oh right then. Okay. Well, you know, well, in the summer, I have lots of salads and mixtures of things and I have some leaves I grow in my garden and chop those up.

Dr Rupy: Oh, you grow your own?

Professor Elsa Welsh: Yeah, just little packets of seeds in a trough, you know.

Dr Rupy: Oh, that's great.

Professor Elsa Welsh: And actually just keep picking them, they're great. Yeah. It's good actually, it's quite cheap too because you you can grow a lot in a small space.

Dr Rupy: Yeah, yeah, yeah. Do you do you eat your vegetables raw to try and get more vitamin C from them? Because obviously heat will reduce them.

Professor Elsa Welsh: I mean you could yes, I I don't it varies. I mean I do have raw vegetables and that's fine, but of course your carotenoids don't get absorbed so well from raw foods. So you know, they're they're you get absorbed more from those if they're cooked. Like if you have so the different carotenes are all the colour thing coloured nutrients and vegetables um and fruits and they're um they may not be needed necessarily for eyesight because you know there's a classic sort of beta carotene which you get in your carrots, you know, you need it for your eyesight. Um but some of the others, you know, they're they're kind of I suppose they're more bioactive and so um so essentially you can get um those um if you cook some of those, the the beta carotene, you cook some of them the vegetables, you get the the carotenes are better absorbed.

Dr Rupy: Okay. Yeah. So some so some vegetables you need to cook to actually increase their

Professor Elsa Welsh: Not always, I just think a variety.

Dr Rupy: Okay, yeah.

Professor Elsa Welsh: Yeah, I think. I mean obviously it also depends, to be honest, on how your food's been stored. I was worked on the food composition tables with McCance and Widdowson as well a long time ago and you know, basically um you know, if you've got an apple and you pick it from the tree, it's going to have lots of vitamin C in it. Sit it in the sunshine and it will start to deteriorate quite quickly. And that's what's happening with many of our fruits and vegetables we don't really know and and to understand there isn't the money necessarily to analyze all the different foods we eat. So we have average values in our food composition tables too, which you may may not know, probably not that interesting for other people.

Dr Rupy: No, this is really interesting, trust me. So the average value of vitamin C in an apple, that that's what's in the table whenever you look up the vitamin C concentration, but that's an average. So there's obviously some apples that are higher, some apples that are lower.

Professor Elsa Welsh: Yeah, and it depends on season and how they're kept. Vitamin C is very labile. You know, that means it's it's it's not very um it doesn't it's not very stable. So um it does it does vary a lot in terms of um when it how it's kept. It's the same with um riboflavin in milk. You know, if it sits on the doorstep in the sunshine, it reduces the amount of that B vitamin in the milk. So a lot of the actually it's mainly the water soluble vitamins that are actually um affected by heat and light.

Dr Rupy: Okay. So they have to make when we put together food composition tables, we have to make averages and put it together. So it gives an idea, you know, but

Professor Elsa Welsh: So the water soluble vitamins, those are the B vitamins, vitamin C.

Dr Rupy: Not so much B12, but the you know, thiamine, riboflavin and so on.

Professor Elsa Welsh: Okay. Any other vitamins that I'm missing? There's some others.

Dr Rupy: A, D and E and K are fat soluble. Yeah. Okay. I think that's it. Yeah, there's yeah, there's some um Okay. So from vitamin C, uh you want to get them from a mixture of fresh uh and uh lightly cooked fruits and vegetables. There's a real spectrum. Is there any way of checking like the vitamin C content of the fruit and veg that you're consuming? Like there's no neat little gadget that can give you an indication?

Professor Elsa Welsh: No, because even the food labeling data um which I worked on too, um that that can be used is is is comes from the food tables. Um so yes, you don't know. One thing I should say is it's not just fresh, frozen vegetables and fruits are really good.

Dr Rupy: Yeah.

Professor Elsa Welsh: And in fact sometimes they're better because they do they get frozen immediately. You know, they're not been sitting around um with deteriorating in some way. So actually they're good and they're actually a lot cheaper. So I I wouldn't knock um you know, fresh sounds great if you can do it, but actually I would be having frozen fruits and vegetables are perfectly great for they're probably got more you know, some of them may have more nutrients in them than the fresh ones.

Dr Rupy: Yeah, we we're big fans of frozen in the Doctor's Kitchen. We get um we get a lot of our berries frozen. We get spinach frozen. We've got peas obviously and edamame. Like super convenient, much less waste. Um yeah, we're we're really big fans of that. And actually we did a bit of work a couple of years ago looking at the nutrient averages, looking at the tables and and we found actually, you know what, it's sometimes higher than fresh fruits and vegetables. And perhaps because the air miles and the handling and the gradual degradation of some of these nutrients as they're left in the supermarket. So that was a real eye opener for us. So yeah, big fans of frozen.

Professor Elsa Welsh: Yeah, no, I agree. I think you know, I think I think basically any kind of whole food that you can find is good for you. The difficulty is not everyone's got the time, the money and the and the energy to do all that, you know. So you have to just do what you can in any situation really, I think.

Dr Rupy: So if we were to quantify the amount of vitamin C rich foods in like handfuls of cooked fruits and vegetables per day, what would the ideal amount be?

Professor Elsa Welsh: Well, I guess I mean, essentially if you're getting your five fruit and veg a day, five portions, that gets you a bit closer.

Dr Rupy: Okay.

Professor Elsa Welsh: I was again, I was having a think last night. So I mean a banana will give you about 10 milligrams of vitamin C. Okay. Um broccoli or something might give you more like 20 and an orange is about 50, you know, so I mean it's not undoable. Once you've had an orange, I mean two oranges will get you to 100, you know, so but citrus is more well, certainly fruit juice too, although that's more expensive and not everybody wants to eat fruit juice. I think there's other reasons as well because of the sugar absorption, but yeah, but um but I think um I think if you're going to have your five a day and more, then you're going to be fine really.

Dr Rupy: Okay.

Professor Elsa Welsh: And a lot of the um summer fruits are better, you know, they've got much higher levels. You know, the strawberries and the blackcurrants and all those things, but you can get those frozen anyway.

Dr Rupy: Yeah, yeah. And I guess like the wider problem is the fact that the majority of the UK population average less than three fruits and vegetables per day.

Professor Elsa Welsh: Uh yeah, I was just looking again at the recent report. Yes, it's it's it's three or less. And actually it's even smaller for people who are older over 75.

Dr Rupy: Oh, really? Yeah. Oh, wow.

Professor Elsa Welsh: Yeah, so and I suppose the thing that we don't know yet and which we we ought to work on a little bit more and probably will be at some point in the future is just how much when you're getting older you really need. Do you actually need the amounts that we actually know about now or do we need the extra overhead in terms of you know, how much extra vitamin C do we need? How much extra B12 and those sorts of things? Partly about how much we absorb, you know, and um as people get older, their guts get a little less efficient as well, I think.

Dr Rupy: Do we become less efficient at absorbing things like vitamin C?

Professor Elsa Welsh: I don't know.

Dr Rupy: Okay.

Professor Elsa Welsh: But I wouldn't be surprised.

Dr Rupy: Uh-huh. Yeah.

Professor Elsa Welsh: You know, we don't really know, do we? Um but I think it would be something we would need looking at eventually.

Dr Rupy: Yeah. I mean, definitely from a protein point of view, the ability to digest proteins reduces, hence why we need a bit more than the guidelines, but yeah, that that's really interesting about vitamin C. So really need to focus on fruits and vegetables. Of course, I mean, having first hand experience working on geriatric wards and in primary care, your appetite diminishes. It's really hard to get that quantity of food. And sometimes you're making the trade off between energy in the form of calories versus the nutrients that we all know are really important for muscle health and stuff. But where possible, I mean, certainly for anyone with grandparents or anyone in their family over the age of 75, 80, you really want to be trying to hammer away at getting fresh fruits and vegetables or frozen. Um you know, even smoothies, I'd be a big fan in this case of getting smoothies into the diet because it gives you energy and I'm less worried about the free sugars in that respect.

Professor Elsa Welsh: Okay, I think we've done vitamin C.

Dr Rupy: So really important for mitochondrial health that we'll talk about a bit more later, collagen, muscle, bones, mitigating inflammation. Um let's talk about another nutrient. Uh you take it's your turn. You you can pick. We've done magnesium, vitamin C.

Professor Elsa Welsh: I'll talk a little bit about iron.

Dr Rupy: Yeah, let's do that. Yeah.

Professor Elsa Welsh: Because I think we've been thinking about iron and anaemia and so on, but um which is important, but actually we've thought much less about iron and iron status in relation to muscle again. So um

Dr Rupy: Yeah, I always think anaemia straight away, make the association.

Professor Elsa Welsh: Yeah. And and actually that the thing with anaemia is it does affect your muscle function anyway because you get tired again, don't you? You can't function so well. So I mean it's clearly important, but um so we were looking at at um in this study in America called the Baltimore longitudinal study of aging where they they have healthy, they enroll healthy people from age of 20 to 90. My PhD student's done some nice work. We were looking at um factors you can measure in blood that you would call clinical biochemistry. Say if you're um you know, if you go to the doctor, they'll measure they'll measure whether you've got anaemia, they'll measure your HBA1C which helps know which is a measure of how well your blood glucose is controlled and that kind of thing. So we were looking at some other, you know, a range of those sorts of what you call clinical biochemistry and um and muscle function and different factors in relation to muscle function, muscle mass. And we did find actually there was a suggestion that actually better measures of of um iron in the blood, ferritin and and um hemoglobin were related to better muscle function in men. So you know, that might encourage some people, you know, if people are interested in their physical activity to actually think that actually, you know, to to consider um iron. One thing which I haven't really thought about saying, but since we've talked so much about vitamin C, you need vitamin C to absorb your iron as well. So that's another reason for having your veg with your other proteins and so on.

Dr Rupy: Why is it that vitamin C is so important for iron absorption as well? Because I've always wondered, I I I've understood the need to combine, particularly if you're vegetarian or vegan, to combine iron with vitamin C, but I've never understood the mechanism behind it.

Professor Elsa Welsh: Now you mention it, I'm not quite sure I know the exact mechanism either. Um it might be about it's not going to be about the form format of iron, yeah. The iron whether it's sort of you know, two or three, Fe2 or 3 plus, but I don't actually know. It it's definitely needed. I'd have to look back on that.

Dr Rupy: Yeah, yeah, I I need to look into it again because I remember having that conversation with my um one of my professors during my nutritional masters and I couldn't figure it out.

Professor Elsa Welsh: It's interesting to know because it's really well known, isn't it?

Dr Rupy: It's really well known. And it's it's I think it's becoming quite like popularized as well about yeah, combining vitamin C with iron, but the mechanism, I always like to think about the mechanism as to why this is important. I mean, there's clearly a study that shows when you pair vitamin C rich foods with an iron source, it increases iron in the blood or

Professor Elsa Welsh: Yes, um I'm just thinking if it's about the red blood cells and how they operate. But actually thinking about it, I don't remember ever seeing anything about why. Anyway, we'll have to

Dr Rupy: All right, well, I'm glad I've sparked something. Okay, all right. So so TBD on the organ supplements, uh but but skeptical is is what I'm getting.

Professor Elsa Welsh: Well, I guess they wouldn't necessarily be any harm, but I suppose the question is whether it's spending money on something that's doing any good.

Dr Rupy: Yeah, yeah, yeah. And you probably just want to get it from from uh whole food sources. So in terms of the best heme sources, I'm assuming, and correct me if I'm wrong, red meat would be the best source of heme.

Professor Elsa Welsh: Any sort of red type meat, yes.

Dr Rupy: Okay. Do we get any from fish at all?

Professor Elsa Welsh: A little bit.

Dr Rupy: Yeah.

Professor Elsa Welsh: Yeah, not so much because it it depends on the colour of the fish.

Dr Rupy: Sure, yeah.

Professor Elsa Welsh: You can sort of see by the colour of the flesh what's different.

Dr Rupy: Yeah. So white fish I'm assuming will have less.

Professor Elsa Welsh: They have some, but it's much less.

Dr Rupy: Sure, much less, yeah. Okay, fine.

Professor Elsa Welsh: Anything that's had blood in it will have heme in it, you know.

Dr Rupy: Yeah. Yeah. Okay. So red meat sources, uh beans, apricots, um vitamin C, make sure you're having those.

Professor Elsa Welsh: Green vegetables too.

Dr Rupy: Green vegetables as well, absolutely. Yeah, definitely great. Green vegetables are definitely getting loads of shout outs in uh the aging discussion in magnesium, vitamin C. Uh okay, great. Um let's go for another nutrient. Uh so we've done iron, magnesium, vitamin C.

Professor Elsa Welsh: So just briefly I could talk a little bit about vitamin E as well, which

Dr Rupy: Let's talk about vitamin E. Yeah, yeah.

Professor Elsa Welsh: A lot of interest in that because it's an antioxidant and there are different form um I was going to I use the word isomers, which means that basically means there are different um they may be the same molecule but they're different shapes in the way they work in the body and some are better than others, should we say. Um but um

Dr Rupy: Am I right in thinking there's like eight isomers for vitamin E?

Professor Elsa Welsh: Yeah, there's the tocopherols and the tocotrienols and so on. Yeah, they're not all the same biological absorbability. But they are um important and I think there was a there was a point where we thought that actually supplements of vitamin E were the cure all for certainly cardiovascular disease really.

Dr Rupy: Yeah, I remember that, yeah.

Professor Elsa Welsh: Um but actually there were some studies that showed nothing really. And um we don't actually have a recommended intake dietary intake guideline for vitamin E. So it's kind of a it's a bit of a it's an odd one really. Um because we know it's important but it doesn't seem to have kind of we need it, but actually it doesn't it's not obvious um you know, these days um perhaps what amounts we need, but the thing is that you know, there's a lot of vitamin E in a lot of the vegetable products foods as well. So um which is one of the things. Um and um so basically we did look at vitamin E in in blood and in bone, how how it related to blood and bone and fractures. And um we did find some relationships with that.

Dr Rupy: Really?

Professor Elsa Welsh: And and yeah, and muscle too. So there was some relationship, not huge, but there was some relationship and and with intake as well. But I guess one of the things that makes it more complicated and I was realizing when we were looking at this was that um vitamin E is used as a kind of way of preserving lots of foods as well. And so you can end up with one of the different isomers um or types of vitamin E that's higher and so having a higher vitamin E for of a certain type may not be actually a good thing. It might be an indication that you're probably eating more um ultra processed foods, that kind of thing.

Dr Rupy: Really? Is that because it's found in lots of oils that are commonly found in ultra processed foods like safflower oil and

Professor Elsa Welsh: Um I think I think it's more used as I think it's more used as a kind of added preservative.

Dr Rupy: Oh okay, I see, I see.

Professor Elsa Welsh: Just thinking about it. Um but yes, I mean there is some, I'm thinking it was coming directly. Well I don't actually think about it safflower oil and so on, I don't know the form, but I imagine it would be alpha tocopherol.

Dr Rupy: Gotcha.

Professor Elsa Welsh: Which is the kind of neutral one and is supposed to be better. But there are others that are found in more processed foods.

Dr Rupy: And where would you get a good source of vitamin E given that it's important for bone and muscle health?

Professor Elsa Welsh: I suppose again, vegetables, green vegetables. Sorry about this. You've got to eat your spinach.

Dr Rupy: Yeah, yeah, absolutely, yeah.

Professor Elsa Welsh: And um and wheat germ, that's very high. Yeah. Um and some of the oils, you know, that the um vegetable oils, but thinking about it, I don't know off hand which ones I haven't really

Dr Rupy: I know olive is good. There's also wheat germ oil as well, which I guess is yeah, from the

Professor Elsa Welsh: And probably sesame oil, I think, but I may be wrong on that.

Dr Rupy: Okay, yeah, yeah, yeah. And would you get, I mean, you'd probably get some in nuts and seeds then, I guess, with those fatty acids and yeah.

Professor Elsa Welsh: Yeah. Great. Okay. So you know we have a uh a saying in Doctor's Kitchen, which is to get your BBGs in every day. So beans, berries, greens, seeds and nuts every single day.

Professor Elsa Welsh: Perfect. Yes. Just do it.

Dr Rupy: Just do that. Literally we have it like stuck on our fridge and I'm just trying to get people to think of BBGs every single day. Because they're going to be giving you, I mean, you've got some some iron and beans, you've got your greens have got everything in by the looks of things. Uh your your berries have got fibre and some of these uh vitamin C and and other antioxidants.

Professor Elsa Welsh: Your polyphenols and all those other exciting bioactives which I'm not talking about today necessarily, but

Dr Rupy: Sure, yeah. And then you've got your seeds and nuts which have got your vitamin E and fibre and

Professor Elsa Welsh: And other and other B vitamins and and actually very nice oils as well in them. So you know, when you look at fat, um well you know, you know, the saturated fat which is the hard fat, don't you? You know, you can see it's hard or a hard oil because it oil would be solid. Um and then you get the very unsaturated ones which are liquid. And obviously we've known for a long time that a lot of very saturated fat is bad for you. Um and you know, I mean probably since the I would say 60s, 70s, you know, there was a lot of cholesterol being eaten as well because of um animal fats and cream and that kind of thing. So that was very traditional for a long time, but you know, people have probably moved off a lot of that now. But um what I was going to say, the reason I was telling you about fatty acids was um yes, so but essentially anything that's got more liquid feel to it is going to be better on the whole. But um those with the um the plant-based omega 3 called alpha linolenic acid, um those um are likely to be they're they're um they may be converted to the longer chain N3 fats, which is the fish oils from fish and so on. So I I published actually ages ago now, but looking at people's people who didn't consume um who consumed no no fish or any of those sorts of things and people who ate meat and then what the blood levels were of people who were vegan essentially, um or vegetarian who weren't eating any of the um meat or fish. And actually their levels, what what what made me wonder was their levels of um the there's two main ones that we look at called EPA and DHA, eicosapentaenoic and docosahexaenoic acid for anyone who wanted to know. Um those were actually not so very different in people who were vegetarian. And there's a whole thing about how much you can convert um from the plant-based.

Dr Rupy: Sure.

Professor Elsa Welsh: Which I think um I haven't worked on that so much lately, but you know, there must be something going on because when you go to populations that aren't eating a lot of fish, those levels, if you look at the graphs of, you know, what plots with intake and and and the graphs of the level, particularly in adipose tissue, it never goes to zero. So it's coming from somewhere. So um and I think probably in Eastern Europe it's it's possibly more important, but um obviously fish and fish oils are very useful and you know, if you can eat fish, then that's fine and if you've got the money, the time and the source of of fish, but actually I have a feeling that um these well, I do know, I mean I've shown it, um you know, there is some conversion. And it's probably greater where you don't have the feedback loop from the pre-formed EPA and DHA that's already in the blood because it allows more of that conversion chain.

Dr Rupy: I've always wondered that because and I think there's a real opportunity to study largely vegan and vegetarian populations that you find in India. You've got a billion people, majority of whom are eating just plants. And if you were to test their blood, I'm sure they're going to have high levels, not necessarily high levels of omega 3, but some moderate amount of omega 3 in their blood and they're not eating any fish. So they're either really good converters from the short chain omega 3 fatty acids to the long chain fatty acids or there's something else going on or they're getting it from a different source. I don't know where.

Professor Elsa Welsh: I mean it must be because we sort of need it. So I think bodies have just adapted to it. And of course, you know, the ALA, the alpha linolenic acid, the plant one, um we have a lot more of that in the diet than we do of the um than you'd get from fish and what have you anyway, unless you're taking fish oils. So you know, you're getting grams worth of it whereas you're getting much less in terms of of the um of the fish um the amount the fish will give you if you're eating it. So um you know, I think I can't believe that we we basically we know that if you smoke, actually strangely if you smoke, you convert more of your your alpha linolenic acid to EPA and DHA.

Dr Rupy: Really? Yeah.

Professor Elsa Welsh: And if you're pregnant, which is clearly not going to. But younger women and pregnant women also convert more.

Dr Rupy: Really?

Professor Elsa Welsh: But it was a bit odd because yes, I'd seen this in some of the studies that they'd done. There was a lot of work done in Reading and then when I was looking at my data, the cross-sectional data, I thought, yeah, it does actually smoking, yeah, the people with who were smoked did seem to have a higher level. I'm not suggesting you should do that.

Dr Rupy: No, of course not.

Professor Elsa Welsh: But I don't know what it's doing to the enzymes that convert them.

Dr Rupy: That's so strange.

Professor Elsa Welsh: Alcohol might also be relevant too.

Dr Rupy: Really? Is it like increasing the conversion to omega 3?

Professor Elsa Welsh: Yeah. Or the plant, yeah, that's right.

Dr Rupy: Wow. Yeah. Okay. Well, I mean, don't take up smoking anyone, but I mean, I personally take a fish oil or an algae oil um for you know, if you want a cleaner source.

Professor Elsa Welsh: Yeah. Well, that's where the fish get their their um N EPA and DHA from is from the algae in the sea anyway, isn't it?

Dr Rupy: Yeah. Yeah, yeah. Okay. Would you put omega 3 on your list?

Professor Elsa Welsh: Yeah. So yeah, yeah. And actually I did do some work a little bit winding back a bit to muscle. I did some work a while back um looking at profile of the diet and um muscle mass.

Dr Rupy: Okay.

Professor Elsa Welsh: Um because well one thing, one thing is that muscle, you know, um fish have got this um anti-inflammatory, the fish oils have got anti-inflammatory activities, haven't they? Um but also muscle needs um basically it uses fatty acids differently. And actually once um once you've been exercising for a short while, you you instead of using carbohydrate, you'll know this I'm sure, it goes onto fatty acids. And so I was interested to know whether if you have more of the um N3s and and the unsaturated fatty acids, if you had um more muscle mass and essentially I did see that. I again that was a long time ago, I published that in the twin study again. So there's something going on there and and the more saturated fat, the lower the amount of muscle mass.

Dr Rupy: So so just to repeat that again for the listener. So if you had maxed out your carbohydrate that you're consuming, but you had a higher proportion of fat in your diet coming from these polyunsaturated fats and these omega 3 fats, you were able to utilize that as a fuel source more readily and

Professor Elsa Welsh: Well, I would say you can, but I didn't show that. What I was just saying is that that's actually what happens. So the biology is that when you if you've used up your carbohydrate, you start to use fatty acids and it's the free fatty acids that are actually going in to create the fuel that go into the mitochondria that then then create the energy and also muscle contraction. But they'd shown some while before that um children's so you can measure fatty acids in in people's red blood cells and in muscle as well. So if you look at red blood cells, they relate the amount of the types of fat relate to the diet. They've shown that in children a long time ago. So it just was interesting to me. Unfortunately when we did that work, we didn't actually find that um essentially the N3s were really positively related.

Dr Rupy: When you say N3s, you're talking about these omega 3s.

Professor Elsa Welsh: Yeah, the long chain EPA and DHA. Yeah, they didn't really relate that well to to muscle. So and it might have been possibly because there was some what we call confounding, so something we couldn't or we couldn't adjust for the fact that people who are older had less muscle and they were also taking more more fish oil supplements or something like that. I don't know. But um it's an interesting one because I think possibly for exercise, you need you know, you'd be better off eating unsaturated types of fats. So the oils that we're talking about than say, you know, a pastry full of saturated fat.

Dr Rupy: Yeah, yeah. Which is where a lot of the saturated fat comes from in our diet, right? From these mixed goods, these pastries and donuts and

Professor Elsa Welsh: All those things, yeah. Those things that we all love, but you know, they don't and they we want to eat them because they're made to what you know, you want to eat them because they've got sugar and fat and they're delicious and everything else.

Dr Rupy: Well, we we've tried to like um mix up some of the recipes that we've got to mimic some of that sort of texture and that cravability. So there's one thing that I've been messing around with. It's it's almond flour. So just simple almonds ground up and then you add um some extra virgin olive oil to that, a little bit of maple syrup and some dark chocolate chips and you mash that together. And honestly, it's like cookie dough. It's so lovely. And it's full of polyunsaturated fatty acids that you can put on your you know, your Greek yogurt or your coconut yogurt or whatever you like. So yeah, it's just it's just about like trying to change people's preferences for you know, away from the saturated fats that are you know, ultra processed to the ones that are going to be healthy.

Professor Elsa Welsh: But also they're very readily available. You know, you go to actually any hospital um you know, forecourt or any station and the things that hit you in the face are all those sorts of foods, you know, it's very hard to find anything else. So if you're hungry and tired and you're out, you know, it's not surprising that those things. And also, you know, um younger people tend to be hungry.

Dr Rupy: Calcium. Yes. Should we talk about calcium?

Professor Elsa Welsh: Yes. So, um we need enough calcium. And we particularly need it for bones. But actually we need calcium too um so that we can contract our muscles actually. So we still need it for many things. It's another, you know, it's as we were talking earlier, it's you know, like magnesium, it's got a lot of different um metabolic processes or processes in the body as we call it that need calcium to work and they need the calcium in the blood to be very um to maintain very tiny um small amount of variation really.

Dr Rupy: Yeah. So calcium levels need to be super steady. We need a good amount coming in the diet. If we don't have enough calcium coming in from the diet, what happens?

Professor Elsa Welsh: Well, essentially the bones give up their calcium really. And that's part of the reason why we get osteoporosis, I think. I mean it's about also the way those cells I was talking earlier, the osteoblasts and osteoclasts work together, but it's also about, you know, we have calcium, there's this compound called hydroxyapatite that's in the bones, causes most of the mineral. There's actually also magnesium in that too. But basically it gets released and so this is one reason why we have less um less calcium in our bones as we get older. And for women, as they get older, they're losing estrogen because of the menopause. So that's that's another reason why we end up with more um more fragile bones. And um yes, I mean for every lady who's sitting next to somebody possibly at home even, somebody else of a similar age, if you're over 50, one of you is going to have osteoporotic bones and possibly a fracture before the end of your life. But men don't get away with it either. Men um one in five men will have

Dr Rupy: Just to emphasize that. So 50% of women over the age of 50

Professor Elsa Welsh: I would say, yeah, 50, 60 will have one or other of them, yeah.

Dr Rupy: Will have a will have a fracture as a result of osteoporosis.

Professor Elsa Welsh: Yeah.

Dr Rupy: Gosh.

Professor Elsa Welsh: I've worked with the Royal Osteoporosis Society for a long time, so yeah.

Dr Rupy: Wow.

Professor Elsa Welsh: But it's just not really recognized. And the thing with the fractures that you have with this with this sort of fracture is they're you know, we know if you fall over as a young person, you do something and you really real big bash that breaks the bone. But just bones crumble. So particularly it's it's um fractures in spine, vertebral fractures. They just occur without really any impact. They're called low impact or fragility fractures. But men don't men don't get away with it either. I mean, one in five men will also have osteoporosis and people don't realize that at all. But men's um men's hormones are declining too. Their testosterone is not going down, it's being um linked to another hormone that binds it, so it means it's not so free. So it's um it's linked and and so it means that the absolute amount of free testosterone is going down, which um affects their bones as well.

Dr Rupy: What is that uh hormone?

Professor Elsa Welsh: I'm just trying to it's sex hormone sex hormone binding globulin.

Dr Rupy: Okay. And so it is do we have any reason as to why that's happening more often?

Professor Elsa Welsh: You mean one of the fractures?

Dr Rupy: No, sorry, with the with the free testosterone being reduced.

Professor Elsa Welsh: That's just biology in men.

Dr Rupy: Oh okay, there's just a simple result of aging.

Professor Elsa Welsh: Well what happens is basically the SHBG increases. Now whether why that secretion um increases, I don't quite know. But it's just known that it is. So it just means there's less of the free testosterone which actually then affects men's muscles too.

Dr Rupy: Huh, okay.

Professor Elsa Welsh: And weakness and so on. So you know, I did um a review with one of the medical students and we looked at interventions where they'd um this was particularly I was particularly interested in in muscle again. Um to see where people had intervened with um micronutrients um to see if it impacted essentially via the hormonal status of um men and women on on um muscle, but actually we didn't really find anything been done very well. But actually some micronutrients impact on both estrogen and testosterone. And um I'm just thinking we certainly know that say winding back to plant foods, some plant foods contain um factors that um more or less kind of connect to say estrogen um and so on um and make it less available because actually what what we have in our bones and our muscles is is is both estrogen and testosterone receptors. And men and women, you know, women also have testosterone, it's just much different from men. But actually men also have quite a lot of estrogen, they don't realize either.

Dr Rupy: Yeah, yeah. Yeah. And are there certain nutrients that we find in food that can what let me ask it a different way. If prof, you were to give a prescription to a lady or a man who's hit 50 and you you say to them exactly that stat, you've got a 50% chance that you're going to have a fracture as a result of osteoporosis by the end of your life. These are the things that you can do today to reduce your risk of that happening. What would your sort of prescription to that individual be?

Professor Elsa Welsh: Well, I would say have a vitamin D supplement.

Dr Rupy: Okay.

Professor Elsa Welsh: Make sure you're having enough calcium and magnesium and get plenty of exercise. You know, that's the key thing really. And then and also maintain a good diet beyond that because there are other things that we've been showing say um it looks a little like um okay, so so dietary patterns, so they're they're the ways of describing how we sets of foods. And um so everyone's heard of the Mediterranean diet and there's some others now that we use in in research as well, healthy eating index, dietary inflammatory index and so on. So we did a recent review of um and also we looked at yeah, so so we looked at those and we also looked at whether people were vegan or vegetarian and so on, what research there was and whether people had fractures or not and also how much that impacted on sarcopenia as well. Um and it does look like a general healthier diet, you know, with with much more in the way of so Mediterranean diet would have um based on plant foods essentially, lots of vegetables, fruits and other sort of cereal foods. And then you get smaller amounts of things like um fish, um tiny amounts of meat at the top and then you know, other other foods in between and you know, much less of the kind of ultra processed foods we're talking about. On the whole, it did look as though people were their bones and number of well actually their fractures we looked at specifically, they had fewer fractures.

Dr Rupy: Okay.

Professor Elsa Welsh: But mainly also those who are vegan or vegetarian seem to be okay if they were taking um vitamin D and calcium.

Dr Rupy: Okay.

Professor Elsa Welsh: So they seem to be important. So I would say whatever you do, you know, whatever you're doing, have um make sure you've got those things. And also I if you can get a bone density test, particularly if you think your family that runs in your family, good idea. There's also the Royal Osteoporosis Society, I'll give you a um a shout out and you can look on their website for anything you need to know. But but it does seem like there are other things that may be important for bone, you know, like um the bioactive foods that we have, you know, um and um and so say like broccoli and so on um and and there's some bioactives they've got in there. Um and some of the other micronutrients we have which we haven't really looked at enough, but they they may well be important too.

Dr Rupy: Which bioactives are there in broccoli?

Professor Elsa Welsh: So I suppose well it's partly um partly I'm thinking um in terms of um so so some of the bioactives that may or may not be helpful for bone are the type of things the phytoestrogens you get in soy. And there's been some work on that but not really so much lately because what happens is that in your I think I mentioned earlier in your bones, you have estrogen, testosterone receptors. So um they can help but sometimes those also the reason why they were thought to be useful for um breast cancer and those sorts of things was they were probably blocking the normal estrogen receptors so from producing too much estrogen that might be causing cancer. So sorry it's a bit of a complicated.

Dr Rupy: Yeah, it's quite complicated, isn't it? Because on the one hand, soy appears to be which is a typical phytoestrogen rich food. Soy appears to be beneficial for reducing the risk of breast cancer. It also appears to be beneficial for bone health. Whether or not that's because of the isoflavones or because of the fact that it's rich in fibre or it's got protein in it. Um it's quite hard to determine, isn't it? But I know that there's that association, right?

Professor Elsa Welsh: Yeah. Well I will say though some while ago I did produce I also did some research in in Epic and we looked at people because I was in we were interested really, you know, personally but particularly was very interested in soy and cancer essentially, you know, and there's a lot of work going on then. Um and I looked at whether people consuming soy or not and their bone density, well bone density is measured using a particular method called heel bone ultrasound.

Dr Rupy: Oh, heel bone ultrasound. Yeah.

Professor Elsa Welsh: Which is slightly different from measuring using a DEXA scan. But anyway, we found

Dr Rupy: Is that just as accurate, the heel bone?

Professor Elsa Welsh: Actually we didn't think it was because when we did that, it was new, but actually it does predict fractures as well.

Dr Rupy: Okay.

Professor Elsa Welsh: Um it's not quite the same measure. It's um but it it does yeah, it does um shown yeah, so I keep we did look at vitamin C and fractures as well.

Dr Rupy: Okay.

Professor Elsa Welsh: And um and found it related um partly, yes, so in men and women in in so I've done different things. I was trying to stick to a slight narrative, but we don't mind going on a tangent.

Dr Rupy: No, we're we're going all over the place. It's great.

Professor Elsa Welsh: But you were mentioning soy and and women and bone density.

Professor Elsa Welsh: So so basically what I was looking at was um bone density and people who ate meat and those that didn't um and whether they ate soy or not. And actually it did appear in the men, I I looked at this really carefully. Some of the men actually had much lower bone density than you'd expect eating soy on a diet in this country. Now I didn't know whether that might be something to do with possibly interacting with testosterone possibly.

Dr Rupy: Interesting.

Professor Elsa Welsh: It if it was, you know, we were very careful with it and I checked everything, but or whether so soy's eaten in the Far East all the time. People are used to using it, cooking it and what they eat with it. I did wonder if perhaps um on the basis of say a more western diet, if it may not be quite so helpful. But um I've not I haven't taken that any further, but I was just interested in that because it seemed surprising really.

Dr Rupy: Yeah. If soy was having a detrimental impact on bone mineral density, do you think that might be reflected in Asian populations who tend to consume quite large amounts of it?

Professor Elsa Welsh: Um I see I think that's I think not necessarily because I think it's what what the baseline, if you look at um how foods are digested, it depends often on what else it's consumed with. So no, and actually I did also do some work when we looked at um men and women in Hong Kong and looked at um diet and fracture risk and so on and other factors because we assumed, I assumed that everybody was very with my colleague Jean Wu, we looked at people in Hong Kong and you know, they're all much more active, they are much lower BMI, they don't drink anything really compared with what we do in this country. Um but I just assumed that they would have much better um bones that would be, you know, they'd be it was fine, but we couldn't really see anything that differed between the countries that made any difference really. It was almost the same levels of fracture risk except for women who had a higher BMI were more protected in England in the UK.

Dr Rupy: Wow.

Professor Elsa Welsh: But um yes, I thought we'd find all sorts of things, but it was really no, there wasn't really so much difference.

Dr Rupy: It's quite interesting. Yeah. Um okay, I'm going to take us away from nutrients and talk about like a dietary pattern that um you mentioned in uh in a previous lecture I think. Um alkaline diets. So what do we mean by an alkaline diet?

Professor Elsa Welsh: Okay. So um so when you eat foods, um there are some that are more alkaline forming in the diet um in the body and some that are more acid forming. The ones that are more acid forming tend to be or basically meat and animal foods and um things like dairy. And then um the plant foods and actually also cereals, so sort of you know, um cereals like bread cereals and those sorts of things. And then basically, you know, the opposite side that create more alkaline effects in the body are fruits and vegetables essentially. Um and there's a way of calculating this um there's a a PRAL index which my colleague um in Germany used um

Dr Rupy: PRAL?

Professor Elsa Welsh: PRAL, potential renal acid load.

Dr Rupy: Mm. Yeah.

Professor Elsa Welsh: And it's about the balance between calcium, magnesium and um protein and now you've got me because I wasn't prepared. Sorry, I just put you on the spot. Yeah. Um and chloride which can be ignored. Sodium, sodium, yeah, that's right. Um and basically those things um balance each other out and and essentially um depending on what the diet is like, if you have a diet that's much higher in vegetable foods than animal foods, then it's more alkali. And I did also publish again which I wasn't going to talk about this at all. Um that actually a diet that's and I have also shown it's related to okay, so so a higher, a more alkaline diet, alkaline forming diet, um does relate to pH in the urine. I showed that in Epic Norfolk where we just had spot urines, but essentially people who had a a um more alkaline urine were consuming more fruits and vegetables and less meat and so on.

Dr Rupy: Gotcha.

Professor Elsa Welsh: Um so there's a whole paper out there if anyone wants to go and look at it. Um and but the thing with spot urines is, you know, your your renal excretion changes all day. So you know, you could have more or less depending on um you know, more alkaline or more acid urine at certain times. So you'd really need to look at it mainly um over 24 hours. But it was interesting that I showed something there. I just couldn't believe it. But it did look as though if you had about twice as much vegetables as animal foods or vegetable plant foods as as animal foods, then that was a good mix where you got it came quite neutral.

Dr Rupy: Okay. And so an alkaline diet, does that I'm assuming that confers benefits. So as a as a as a spot test, you know, doing a pH in urine that is essentially a proxy for how much fruit and vegetables you're having in in your day-to-day.

Professor Elsa Welsh: So yeah, sort of although it's it's slightly um it's compounded by the sort of acid um formation of from fat as well essentially. But it does it does give you, I mean you'll find if you try it, it does does change. And it's one thing I've always been meaning to do is actually

Dr Rupy: Really? Just do spot urines on yourself?

Professor Elsa Welsh: Well just do interventions and see if it changes because you can also measure um pH in in saliva as long as you've got a clean mouth.

Dr Rupy: Really?

Professor Elsa Welsh: Yeah.

Dr Rupy: Ah.

Professor Elsa Welsh: So if you ever want to get on with that, I'm happy to have a chat with you. I've gone right off, but but the thing is I suppose in the end I haven't focused so much on it because it is about this balance between, you know, plant foods really and not so much in the way of animal foods. But um and it's only really that much of a problem in older people. Again, we're going back to to so the way you get rid of your alkaline and acid um ions is through the kidney. And if you're I'm we talked about this gradual slowing down of um of the way kidneys function. So really um the issue is when if your kidneys aren't working so well, then you can build up a small acid type of um environment in your blood. It's tiny because again, it's the whole thing again about that all, you know, the body works really carefully to make sure it's all the acid base balance again is like the calcium. I mean you've really got to have that right. And of course there's also the input from respiratory um when you're breathing. But actually overall it does despite all that, there is some relationship between this PRAL index and the amount of alkaline food you have in the diet um and we did show it was related to fracture risk actually.

Dr Rupy: Really?

Professor Elsa Welsh: So yeah, I published it looked as though it's protective.

Dr Rupy: So a more alkaline diet, i.e. one that has more fruits and vegetables in, less acid forming ingredients, i.e. meat, might be protective against bone uh might be protective for bone mineral density, i.e. preventing fractures.

Professor Elsa Welsh: Yeah. Again I've got publications you can look at.

Dr Rupy: That's so that's so interesting. I mean like I I I wouldn't have made the association between that, I think.

Professor Elsa Welsh: Yeah, I I mean

Dr Rupy: And also like just just to highlight your point about just how well controlled the body what how tightly controlled pH is in the blood, you know, it's a 7.35 to 7.45. And nothing really disturbs that. Um but the body works really hard via the respiratory systems and the metabolic systems to ensure that there is enough buffering going on to make sure that to maintain that that very tight control because that's the optimum pH that you know, your enzymes and and everything else is working at.

Professor Elsa Welsh: So I kind of got to this partly because you know, as I worked as a dietitian again, you know, and and um having to give people um renal people with renal failure, low protein diets because that's what we used to do. Um and it was about, well I think you know, to an extent the probably practice has changed a little bit, but it was about the fact if your kidneys are working fine, then whether I think if you've got a high acid load, it doesn't matter that much. But once once your kidneys are not working so well, all these things come to matter a lot more. And it's when you might also have too much magnesium, you know, the sort of things that start to go on. So it's about how your kidneys are functioning really.

Dr Rupy: Any other benefits of having an alkaline diet beyond bone mineral density and fracture risk?

Professor Elsa Welsh: Um because you hear a lot

Professor Elsa Welsh: And also our muscle actually. I'm pretty sure I've looked. Yes, yeah.

Dr Rupy: You hear a lot about alkaline diets as a means to sort of prevent cancer and stuff. I think that's that's the popular use of the term alkaline diet that if people Google alkaline diet, that's unfortunately they're not going to see your paper. Uh the first thing that pops up is going to be some person's diet.

Professor Elsa Welsh: Yes, I was thinking actually I did some a long while ago and didn't actually publish it. I had a paper ready for publication that looked at HBA1C, which is you know, a measure of how well your blood glucose is controlled. And actually there was a relationship between a more acidic diet and a higher um worse blood glucose control. But then that probably goes back to the nutrients that are in those foods, you know, the potassium and so on. You know, the whole thing with vegetables and fruits, they give you a lot more of the the good nutrients that you need and the good we call them you know, um minerals I would say.

Dr Rupy: Okay, great. Anything else about alkaline diets or have we done that, do you reckon?

Professor Elsa Welsh: I think so for now, yeah.

Dr Rupy: I think I mean I'm a big fan of this idea about how it changes the what the fact that it changes your pH in urine. I think that needs like it warrants further investigation.

Professor Elsa Welsh: Yeah, absolutely. Yes.

Dr Rupy: It's so interesting.

Professor Elsa Welsh: I've been meaning to do it for a while actually, but I just um and and it also depends on what else you're eating. So if you've got um you know, you're having a certain amount of meat and then you up your vegetables, then that might make a difference or you know, um and you probably will see it. I mean it does there are other things like say if you're taking supplements with calcium carbonate in it, it will come out really nicely alkaline and that's just the calcium carbonate in the supplement. Because a lot of vitamin C supplements contain calcium carbonate.

Dr Rupy: Oh, really?

Professor Elsa Welsh: Yeah, so they're kind of the carrier is sort of that. So you'll suddenly think, oh great, and then you realize it's not about it's not about what Yeah. Yeah, so those sorts of things because

Dr Rupy: Well if there's a budding medical student out there, you know, they should work under you to do some work with that alkaline diet.

Professor Elsa Welsh: I've got lots of different projects on at the moment, but yeah.

Dr Rupy: I'm sure, yeah. That's right. Um let let's finally touch on, I mean we've talked about it within the nutrients that we've discussed here, but mitochondrial dysfunction. You know, this is something that you're doing a lot of research on ongoing at the moment. So you you briefly mentioned it before, but if you were to describe mitochondria to someone, how what how would you describe them?

Professor Elsa Welsh: So basically, you know, we've got all these cells in our body and um we have to create energy to do anything. And so we've got these they're like little engines in the cell. Um and these tiny little they're completely on their own in in the cell almost, well not quite, but they they sit there and you can see them, you know, in in in um with special methods of looking at them. But basically without them we couldn't really generate energy. And there's something called ATP which generates energy um adenosine triphosphate um which is the whole which then goes used to sort of for energy and also for muscle contraction and so on. Um and these mitochondria are susceptible to different micronutrients, but not a lot of work's been done. But we're pretty sure that magnesium's one.

Dr Rupy: Okay.

Professor Elsa Welsh: It's important. Um and actually we did look again, I didn't mention this earlier, we did also look at magnesium and muscle and how that related to function and that's um that was in the Baltimore longitudinal study of aging and we did feel it found it related too. So that was um useful. Um so going back to mitochondria, so mitochondria need other things, they need nutrients to work like like us. So they need B vitamins and all sorts of other things. And I began to wonder whether actually um or vitamin C, there's lots of reasons why vitamin C would be important to mitochondria. And we were thinking about this um and also what we were finding was seeing that lots of people um the women in particular seemed more susceptible to having lower intakes of vitamin C and how that affected their their strength and function and so on and the amount of muscle mass they had. So we've putting two and two together, we've got a feasibility study where we're we're looking at women who don't eat fruits and vegetables and probably don't have very high levels in the blood. And then we're doing using a special MRI, which is magnetic resonance imaging technique where we can look at the at the way the mitochondria are functioning to see if it if they function better after having vitamin C.

Dr Rupy: How would you deliver the vitamin C?

Professor Elsa Welsh: We're using supplements this time.

Dr Rupy: You're using supplements. Oh, interesting.

Professor Elsa Welsh: Yeah, because we want a continuous amount and we've got placebos as well. So we because difficulty with human studies, you can't really blind people to whether or not you're giving them broccoli or not.

Dr Rupy: Yeah.

Professor Elsa Welsh: But actually with supplements you can.

Dr Rupy: You can. Yeah, yeah.

Professor Elsa Welsh: And but also then we know that's the thing that's changing.

Dr Rupy: Interesting.

Professor Elsa Welsh: So we shall see how that works out. We've um

Dr Rupy: And you're going to measure blood levels of vitamin C?

Professor Elsa Welsh: Yeah. So interesting.

Dr Rupy: So finding people with low fruit and veg intake, hence low vitamin C. You're going to do what how do you tell the mitochondrial function from the MRI?

Professor Elsa Welsh: So there's a special, I know my colleagues are real expert, but there's um it's also when you um create ATP, there's a phosphocreatine and there's a sort of different peaks in the um in the spectra you get out the MRI. And so we're looking to see a change in that.

Dr Rupy: Ah, interesting. Because I thought maybe a muscle biopsy is the is that another way of determining mitochondrial function by doing a biopsy of the muscle and actually looking at the

Professor Elsa Welsh: I guess you could. I guess what we're looking, you'd have to sort of want it to be in a solution to be working. So what we're what we're doing is also looking at people's um getting them to do some movement and then measuring this as well, the change. Um you were say yes, so you're saying um whether it work in muscle cells, it might or might not. I did meet um someone again at that conference I went to when I met the folks who are studying the magnesium and he was a cell biologist and said that basically um you couldn't keep your muscle cells alive unless you put vitamin C in, absolutely given, they wouldn't survive at all. So it's clearly important. Um it's another way of knowing that.

Dr Rupy: Phenomenal. Okay, great. So mitochondrial health, magnesium, B vitamins, vitamin C, mitochondria are obviously very important for the generation of energy, hence to support your muscles and the way they work. Um and I guess exercise is probably the best way, right? To

Professor Elsa Welsh: Yeah, but I I guess the thing is you see, um if you if you have a diet that's very deficient in these vitamins and you might wonder why because we know that that most of these vitamins lead to fatigue. You know, you can be vitamins and so on, you get fatigue, B12 likewise. Um vitamin C, scurvy, tiredness, they all have this kind of tiredness problem. So really um you know, if it's um it's not adding protein is is all right providing you've got those other nutrients, but you need to have those otherwise I don't think it's going to work.

Dr Rupy: It's not going to do anything, yeah.

Professor Elsa Welsh: It's not going to do anything. It's not going to improve anything.

Dr Rupy: Not in isolation.

Professor Elsa Welsh: Amazing. Elsa, this has been really enlightening for me to learn about these different micronutrients. I really hope the audience get an idea about, you know, healthy aging, improving your muscle health because you have this um phenomenal graph about how, I mean it's a brutal looking graph about how our muscle health declines after the age of 30. And I don't think many people appreciate that this aging process starts as early as that. Um and you know, the more we can drum the drum home the message around getting these nutrients in your diet, not necessarily just from supplements, but from whole fruits and vegetables and getting those dietary patterns honed in at an early age, coupled with lifestyle changes, you know, we can really bend that curve and and flatten it out as much as possible.

Professor Elsa Welsh: Because I mean people, the trouble is they don't notice they're losing the the muscle composition. You don't notice that. You don't have any way of knowing that. But people do notice when they're getting less strong and they can't open things or that, you know, that becomes obvious, but that's probably 50s and 60s, by which point you've lost a lot of the muscle. And men lose muscle faster than women. They start off with much more, but they lose it faster.

Dr Rupy: Wow.

Professor Elsa Welsh: Whereas women have much less to start off with, we just biologically do on the whole unless you're an athlete or something. And so it goes down more gently, but for men it's a very strong curve. So I think really it's about it's about actually it's about losing the absolute amounts, but also some other work we've got going on is actually looking at how how it changes with age, um so muscles change with age. So the structure changes. So there's a lot more fat infiltration and so on. So although you might appear to have a, you know, your leg might look the same size, it's got a lot more fat in there and a lot less active muscle tissue or um muscle cells. So those things are all happening. So I think the more you can have a decent diet and and get on your micronutrients because then that will help you keep going. You might not feel so, you know, hopefully you won't feel so tired so you can keep walking or whatever you're going to do. I mean even walking is good, you know, if you do nothing else really, keeping walking is important, I think.

Dr Rupy: Amazing. Elsa, this has been great. Thank you so much. I really appreciate it. And uh I I look forward to reading some more of your papers, particularly the one around alkaline diets and the pH in your urine.

Professor Elsa Welsh: Yeah. Okay.

Dr Rupy: Brilliant. I hope you enjoyed it.