Dr Kate Gregorevic: While a lot of people will do walking, the thing that people aren't doing is strength training. And if you want to be jumping out of your chair when you're 90, then you need to keep your legs strong, and it's one of the absolutely, you know, best protective things you can do to keep things going for the longer term.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine, and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition, and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. One of the greatest gifts of being a doctor for older adults is the constant reminder that life is fragile, finite, and precious. That is one of the sentences taken from my next guest's book called Staying Alive. Dr Kate Gregorevic is a geriatrician and internal medicine physician. She works in both acute hospital medicine and community settings and has completed a PhD looking at the impact of positive psychosocial factors in the development of frailty in older adults. And we have a conversation today all about looking after your parents and looking after yourselves with the goal of looking after your health in older age. Lifestyle medicine is a core feature of Kate's clinical practice, and nutrition, exercise, and sleep are obviously integral to developing plans to optimise her patient's health. And her approach goes beyond physical by working with people to identify their own priorities and values. On today's show, we talk about how to balance the need to change health behaviours to improve longevity with the need to enjoy today. We also talk about the importance of social and emotional wellbeing in any definition of health, the perspective of a geriatrician and actually what a geriatrician does in hospital, assessing someone's readiness to change and tips to motivate them. We talk specifically about sarcopenia. Now this is a subject that I don't think gets enough attention and is something that is a big, big problem in older age adults. So we define it and we talk about mechanisms to try and improve it. We also talk about the prescription for healthy aging, and this is a teaser, squats, purpose, and plants, and you'll know exactly what that means later on. And also the impact of loneliness and how that activates a stressor response. This podcast is for information purposes only. I do highly recommend that you share this with loved ones and also friends and family that you feel that could benefit from it. Please give us a five-star review and comment as well. We try and go through all of them. But without further ado, here is the podcast with Dr Kate.
Dr Rupy: Kate, thank you so much for joining us on the podcast. It's a pleasure to have you here.
Dr Kate Gregorevic: Thank you so much for inviting me to be on. I'm a big fan of the podcast.
Dr Rupy: Oh, that's good to hear. So we were first connected when I spoke at one of the lifestyle medicine conferences for Australasia and you were comparing the session. I just wanted to ask you about the current state of lifestyle medicine and what the general consensus is amongst medics in Australia and that part of the world, and how you got involved in it as well.
Dr Kate Gregorevic: Yeah, I think lifestyle medicine for me is absolutely essential to the way I practice medicine. And you know, lifestyle medicine is a kind of new and fancy term for something that we've been really doing for a very long time. And you know, I'm a geriatrician, so I'm a specialist for older adults, and the person who founded geriatrics was a UK physician called, I believe, Marjory Warren. And her amazing contribution to getting people better was to get people out of bed and to see what mattered to them and get them moving. And you know, it's such a simple thing, but it was revolutionary at the time. And in my day-to-day practice, the thing I love about being a geriatrician, I get to work with this amazing team with physiotherapists, with dietitians, with social workers. And we really, we don't look at making things perfect for our patients. We look at saying, what really matters to you and how do we achieve that? And you know, sometimes there's a bit of some misperceptions about lifestyle medicine that it's very alternative, that it's not mainstream, but it is absolutely integral to the way I practice medicine at a very large mainstream hospital.
Dr Rupy: Yeah, I love that about Marjory. I had no idea that that she was almost like, you know, the founder of geriatrics and the simple act of getting people out of bed and moving was sort of the core. I mean, it makes so much sense. And just for those who don't know what a geriatrician does on a day-to-day basis, why don't you give us a little insight, a window as to what geriatrics is and what your day-to-day is?
Dr Kate Gregorevic: Yeah, so I'm a medical doctor and I am a physician. So we do the same early training as cardiologists, gastroenterologists, as endocrinologists. Then I've subspecialised in geriatric medicine. And my day-to-day varies a lot depending on my day. I work in acute general medicine, so people who've just come into hospital unwell. I do some work in the community, which is really great and often so much more about helping people really thrive in where they want to be. I do some work in rehabilitation, I do some work in perioperative medicine. Basically, I get to work all over the place and that's one of the things I really love about my job.
Dr Rupy: Yeah, that I mean, it's awesome because I did a bit of Jerry's when I was training to be a primary care physician. I did old age geriatrics, I did, sorry, old age dementia, old age psychiatry, as well as general medicine. And it is amazing just how diverse this field is because on the face of it, you know, Jerry's is just defined by, okay, we're treating people over a certain age. I can't remember what it is in Australia, but over here, I believe it's 65 plus, or depending on what hospital you go to. But that population just have such a diverse range of medical conditions, but also social circumstances as well. No 80-year-old is the same as another 80-year-old. Although medicine sometimes inappropriately classifies them. Would you agree? What are your thoughts on that?
Dr Kate Gregorevic: Yeah, and that is just such a huge part of what my job is. And you know, by the time someone's 80, they've lived a life. They've had various different education, they've had different work, they've had different financial situation, they've had different relationships and life experiences. And all of these things come together to create someone's health status at this age. And so yeah, no two people are the same. And we do have generic cutoffs related to age, but two people who are 80 can be vastly different ages. You know, we've got leading politicians who are 80. And some of my patients are in their 50s and they've got geriatric issues. And sometimes it's to do with, you know, bad genetic luck, but far more often it's to do with what's happened to them in their life.
Dr Rupy: Yeah. So what compelled you to go into geriatrics as a specialty yourself? What were your early experiences with the medicine?
Dr Kate Gregorevic: Look, it was a slight accident at the time. I'd started off training as a rheumatologist and I had my first baby and I was on maternity leave and I wanted to go back and there was a part-time job in geriatrics. And I absolutely loved it once I started. I love that I get to work in a really holistic way. I love that I get to work with an interdisciplinary team. I love that for my patients, it's not about, you know, making one aspect of their care perfect. It's really patient-centred care and it really integrates not just medicine, but also a lot of the social things going on around them. I also get to work with really, really great other clinicians. Geriatricians tend to be very nice people.
Dr Rupy: Yeah. You know, I agree actually. One of my fondest memories working with a geriatrician was how they were fastidious on having a tea break mid-ward round. And I loved it. Everyone sat around, you know, everything stopped, you know, obviously outside of emergencies. And that that sort of like homely family-orientated feel of the geriatric ward is really nice. And I think, you know, getting to know some of the most incredible people, the incredible life stories of our patients is amazing. And I think Jerry's, particularly in the medical field, has got this inappropriate chip of it being, well, just old people who are grumpy and you just throw some medications out and everyone's got blood pressure issues or mobility issues, you walk around the ward and that's it. They we oversimplify it. And I think, you know, that there's it's just so complex.
Dr Kate Gregorevic: Oh, it is. It's so complex. And that's again, one of the things I love about it, you know, and the physiology of aging is so complex and then seeing how that works out in someone's life. And you know, the thing as well about my patients, and this is one of the lessons that I take from that and apply to my everyday life. People have got this real wisdom when they've lived a lot of decades. And people, you know, resilience is a learned skill and tends to go up with age. And when I say to my patients, you know, what's important to you? No one has ever said to me, I want to live as long as possible. They all say things like spending time with my family. I, you know, work doing this charity work that I do. It's always something about human connection, something about helping. And you know, it's such an important thing for me to keep mindful of in my everyday life.
Dr Rupy: Yeah, let's talk about that actually, because I'm interested given your extensive experience being a consultant in geriatric medicine. What what are the key learnings that you've had from patients themselves? What what are the the key things that have you've picked up by speaking to people that you've put into practice in your own life?
Dr Kate Gregorevic: Yeah, definitely the importance of human connection. And you know, health, well, we often have such a reductive approach and it's all about the physical, but social and emotional health are just as important as the physical side of it. And that means human connection. And that's been something which unfortunately lately has been lacking, just because of all the restrictions around COVID. And it's really brought home to me how important that is to helping people recover when they get sick. The other thing is that happiness isn't about, you know, material possessions. Again, I've never had any of my older patients say to me, I'd be happier if my house was bigger or if I had that designer wallet. It's always, you know, one patient I remember saying to me, I want to get better because I want to go dancing with my wife again. And they were in their 90s and they'd gone dancing for the last 70 years. And I think the other thing as well, when I see people who are doing really well in older age, they're still curious and they're still learning. And people sometimes have this perception that as you get older, you lose the ability to learn new things, to have new ideas, to contribute, and it is just not true. There's so many examples of people doing fantastic things in that area.
Dr Rupy: Yeah, it was it was interesting when I was chatting to Dan Leviton about the aging mind and stuff. One of the things that we talked about was how aging almost needs a bit of a rebrand. Life, you know, from the perspective of a 20-year-old or even a 30-year-old sort of seems to stop at age 65 when you retire. But in reality, like you said, you know, a person who ages well is someone who still maintains their curiosity, is still excited to learn new things. And that actually has some benefits to cognitive health and physical health, right?
Dr Kate Gregorevic: Yeah, absolutely. And a huge part of that is purpose. And the research around that is so interesting. People who've got a higher sense of purpose, it is actually protective against dementia, and it's also protective against cardiovascular mortality. And I think it's when people still feel like their lives matter, they still feel like things are important, they take care of themselves. But I do suspect there's also some biological positive impacts from that.
Dr Rupy: And when it comes to the reality of actually trying to instigate a lot of these things, and we'll talk about a few more in terms of nutrition, the microbiota, but how do you cultivate purpose from the perspective of someone who is from that older generation, perhaps has some ingrained mannerisms within themselves or someone who's listening to this who might be middle-aged as well. How do you cultivate that that feeling of that human connection, that purpose and and spark that curiosity?
Dr Kate Gregorevic: Yeah, and it can be really challenging, especially if people have got strong preconceived ideas. One thing I do is I always ask my patients what's important to them. You know, what matters to you? What do you like to do all day? And try and frame things around that, because I think if things don't matter to someone, they're not going to make any positive lifestyle changes. And I guess as well with my patients, I do often see them with their sons and daughters who are in their 80s. And particularly if the parents have got age-related diseases, they those sons and daughters are often extremely motivated to make some positive changes themselves.
Dr Rupy: Yeah. And you know, in a ward environment, let's say you're discharging someone and you know, how do you how do you tap into that readiness to change? And and how do you actually cultivate that that energy for them sometimes? I mean, you spoke about, you know, what motivates them, what inspires them, but you know, I'm just trying to think from the perspective of someone who's listening who might have grandparents and they are limited by their mobility, they're limited by their their connections, their ability, particularly right now as well. What what kind of things have you come across that might be insightful for those people who are trying to look after their parents as well as look after themselves as they as we grow older?
Dr Kate Gregorevic: Well, I guess when they're leaving the ward, they're often very motivated to change and do everything they can to get home. Being in hospital is an amazing motivation. No one wants to spend time with us and I get that, it's fine. But yeah, around the home, I think as well, it's I think often the biggest thing is helping people overcome ideas about what they can and can't do. And you know, a lot of my patients in their 80s, I get some pretty, I get some real looks when I tell them they need to start doing exercise, especially doing resistance training. Yeah. But you know, to their credit, they listen, they go and see the physiotherapist, they do their exercises. And but again, it's just about framing it for things that matter to them.
Dr Rupy: Yeah. And and when it comes to, let's say, diet and and you're trying to suggest to someone who might have been eating the same thing or, you know, has a particular taste and they're reluctant to change. Do you have any any sort of top tips or or things that you've been successful with when it comes to trying to instigate changes for the benefit of their health and mental wellbeing?
Dr Kate Gregorevic: Yeah, it's it's really, it depends on the group. So with my particularly frail older adults, it's often more just about getting those kilojoules in. But when people are a bit younger, when they've got a bit more sort of scope to make positive benefits in the longer term, you know, I think one of the big things about diet, and I'm sure, you know, you know more about this than I do, but I think one of the big things about diet that gets missed as well is that enjoying food needs to be absolutely central. And that's so often gets lost and we make healthy food sound, you know, awful and reductive. And for anyone at any age, if they're wanting to make positive changes, it really does need to be framed as, you know, making food that's really tasty.
Dr Rupy: Yeah, yeah. And and within the context of them actually being able to cook food as well. I mean, a lot of patients that I've come across, you know, they they do have carers, they do have support mechanisms that they have to rely on. And and trying to fit that within the context of what is achievable for them is quite is quite challenging as well. Are there are there things that you've developed perhaps in your practice or even things that you've come across within the community that can help with improving the nutrition of the of the of the increasing aging population that we're going to be dealing with now and in the future?
Dr Kate Gregorevic: Malnutrition is actually a huge issue in frail older adults. And you know, I've even seen things like scurvy, which you know, you just don't expect. And when people are socially isolated, perhaps they live alone, they've got limited financial resources. And again, they don't they don't have that motivation to cook for themselves. You see some people who live on very restricted diets. And it's often just trying to get meet people's really basic nutritional needs. And it can be a very hard thing. You always got certain programs where we can get meals on wheels, and like food delivered, we try and get families involved, but for the most vulnerable, the biggest issue is just meeting basic dietary requirements.
Dr Rupy: Yeah, yeah, yeah. And so one of the things that I remember learning during my nutritional medicine masters was about the aging microbiome. And you've talked about this in your book as well. I should mention the name of your book. What's the name of your book again?
Dr Kate Gregorevic: Staying Alive.
Dr Rupy: Staying Alive. Aptly named book. You talked about the aging microbiome and and what happens during that. And I wonder if we could just double click on what happens to the microbiota as we age, why that happens, and what kind of things we can be thinking about in terms of additions to our diet, but also the suite of lifestyle interventions that we have to mitigate against the reducing diversity of that population.
Dr Kate Gregorevic: Yeah, so exactly as you said, the diversity reduces with older age. But even more than that, there's a study that came out of Ireland quite a few years ago, and it showed that people who were frail, living in residential care, had a less diverse microbiome, and they had different predominant bacterial species to people who were more robust and living in the community. Now, with this sort of thing, it's really hard to prove chicken or the egg, because often in residential care, diet isn't great. But and but you know, it's highly plausible that with the reduction in diversity of the gut microbiome, with the changes in the predominant bacterial species, that you are getting an increase in exposure to harmful bacterial products, and this could be potentially a driver of frailty, because frailty is itself associated with immune dysfunction and inflammation. And so, you know, we need more research in this area, but I, you know, the way I take it is that I think it's all the more evidence just to keep eating your vegetables, eating that huge diversity of plant fibre, and you know, the stuff that our garden, you know, gut needs to stay healthy.
Dr Rupy: Yeah. Do you have any perspective on supplementation, specifically probiotic supplementation, vitamin D, and even protein supplements as well?
Dr Kate Gregorevic: So, I guess, so with the, look with the probiotics, there's some evidence for constipation in older adults. I guess my kind of reluctance with probiotics are a couple of things. Number one is that you're only looking often at one or two species comparing that to a super diverse gut microbiome. The other thing is, I don't think taking a probiotic, you know, you can't grow a seed in concrete. So a probiotic's not going to replace giving your gut microbiome all that fibre that it needs.
Dr Rupy: I love that analogy, a seed in concrete. I'm going to borrow that one. That's a good one. And with vitamin D, which is commonly low in in the older adult population, do you have a suite of sort of things that you tend to look out for or?
Dr Kate Gregorevic: Look, not particularly. Vitamin D is so complex, and we supplement when it's low, definitely. There's not convincing evidence for giving vitamin D routinely to everybody. And with vitamin D, again, it's really interesting. It's we are, I use, you know, one tablet once a day usually. Giving people intermittent high doses is actually linked with falls. And there's been a couple of studies looking at that. So giving like monthly high dose vitamin D seems to increase falls, and it's not entirely clear why. But again, with bone health, I think that the approach around that has often been a bit reductive. And you know, we have this thing of we give vitamin D, we give calcium to get the bones as strong as possible. But you know, bone is a living dynamic tissue. Bone has a very good blood supply. Bone responds to the stresses going on around it. And so diet is one part of it, but you've also got to move, you've got to stress the muscles, you've got to keep all of that strong to tell the bones to keep turning over and keep making new bone.
Dr Rupy: Yeah. I on the subject of bones and muscular skeletal health, I wonder if we could double click on sarcopenia. I don't think it's talked about enough from a nutritional point of view, mainly because people who are perhaps interested in nutrition and wellbeing are of a younger generation and they haven't come across sarcopenia until perhaps one of their, you know, grandparents is taken to hospital or they become immobile for whatever reason. Could we describe what sarcopenia is, why it's so troublesome in the older community, and what kind of lifestyle, nutrition, and other interventions we have to to try and treat it?
Dr Kate Gregorevic: Yeah, sarcopenia is a really large problem in older adults. And in countries like the UK and Australia, the biggest cause of later life disability is actually inactivity. And that relates to sarcopenia. And so a lot of factors contribute to sarcopenia. So disuse is a big one, but it's also related to obesity, it's related to diabetes. It's, it's related to, and there's a lot that we can do to improve it. We touched, you mentioned before protein supplementation, which I then didn't follow up afterwards. And a low protein diet in older adults is linked to worse outcomes. And you know, I do see a lot of people who are having a poor quality diet and part of that is not enough protein. But again, there's no good reason you can't get all the protein you need from food. And it's highly achievable to get it. But it's just that for various reasons, some people can't quite manage it. But with that is always my preference to try and get things through food. But the other part of sarcopenia is to do strength-based training. And that's something that I think the earlier you start, the better. And you know, particularly women, we often think of strength-based training as, you know, young guys getting giant muscles in the gym. But you know, really it's women who start off with a lower peak muscle mass than men. And that plays out in older age with osteoporosis and with, you know, sarcopenia to the point that they're struggling to get out of a chair and end up in a nursing home.
Dr Rupy: Yeah, yeah. What kind of exercises?
Dr Kate Gregorevic: Strength and resistance training. So basically moving your muscles against a load. So it can be body weight or it can be weights. And as we get older, we lose what's called fast twitch muscle fibres. And these are the fibres that, you know, when you think of a sprinter, but it's also when you stumble on the street, they're the things that kick in quickly to stop you falling down. Yeah, and doing that also loads the bones. The bones then get the idea, oh, hang on, we need to work here. And so it also encourages bone strength. And there's studies showing that people do who do long-term resistance training, you decrease your risk of osteoporotic fractures.
Dr Rupy: That that's a really interesting point about the fast twitch muscles because a lot of what I see in the emergency department when it comes to older patients is falls. So, you know, the simple stumbles, the simple, you know, the curb's a little bit higher, the the irregular floor, perhaps the ferrule on the end of your walking stick is slightly damaged and you don't realize, and then that leads to a tumble and that can lead to head trauma and that leads to an extended hospital stay. And unfortunately, that can sometimes be the just the the straw that that breaks everything and leads to a catalogue of errors later on. And I think, you know, protecting our ability and our ability to remain mobile using strength, leg strengthening exercises is a fantastic, fantastic tip. Are there specific leg exercises that you find work better or that are easiest to attain?
Dr Kate Gregorevic: I mean, you can even just for some people just simply practicing standing up out of a low chair without using your arms and doing that five times a few times a day. But generally, you know, squats are great, but generally for people, if you're not as young anymore, and if you haven't done resistance training, I'd recommend finding an experienced and skilled trainer. I don't know if you have exercise physiologists over in the UK or physiotherapists, but it's not about working out to the point of exhaustion. It's about working out in a way that you're using proper technique, that you can still do the exercises properly, and expecting to build your strength slowly.
Dr Rupy: In terms of, uh, sort of cultivating that sense of purpose, I guess, and community, are there things that you've you've you've come across that are particularly effective?
Dr Kate Gregorevic: Yeah, and this is, you know, something I I learned from my patients. And the ones I see are the ones who've got these really meaningful social connections. And I think it's loneliness is an interesting thing because some people are quite, they are, they they like solitude and it doesn't cause them stress. But for some people, it's that feeling of disconnect. And I I know some people and they live with their, they live with other people, they might live with a spouse, and they still feel really lonely. And when we feel lonely, we activate all those neurological and hormonal stress responses that over the longer term can be so harmful. And so it's really not about, it's about quality, not quantity.
Dr Rupy: Yeah, yeah. I you know, loneliness, I think is coming to the public knowledge these days about how impactful it can be to not just mental wellbeing, but physical wellbeing for through the mechanisms that you've just described, activating stress response pathways and inflammation. It it's one of the hardest things I feel to try and tackle from the perspective of a primary care physician with eight or nine minutes per patient, you know, we might be doing a home visit. It's not like I can prescribe something to treat loneliness. Are there any things that you've come across in your clinical experience, but also perhaps outside of that, that can try and help with this chronic loneliness that we're experiencing these days?
Dr Kate Gregorevic: Oh, look, I think it's really hard and especially because loneliness is a stress state and then people who tend to be in that state tend to be sort of a bit hyper alert and less and even less able to connect with others. And you know, I think really in a lot of ways, this is where, you know, social determinants of health and the individual, you can't pick them apart. And it's one of the problems we have in our society that we we sort of people who are frail and older often are hidden away. We don't have them, we don't see people out and about very much. You know, we all live in these houses and we've set up this really individualistic society that really falls down when someone hasn't got the same ability to get out and access it that they used to.
Dr Rupy: Yeah, yeah. It's and and it's been no more apparent than of late with obviously lockdown and the inability of people who are already poly-mobile but have to shield being able to go out and stuff. And so I think we need to find more effective functions of trying to treat loneliness these days. And and technology can be a force for good from that perspective. I mean, the very fact that we're having this conversation across hemispheres is is amazing.
Dr Kate Gregorevic: It is, it is. And you know, we've had to really readjust to how we connect, but there's been some, I mean, there's been some positives in getting more used to doing things over Zoom as well, you know, get used to see people you wouldn't normally see from far away.
Dr Rupy: Yeah. Yeah, yeah. I've I've definitely had that experience with my friends. Um, well, look, this has been awesome. I think, uh, you know, those are some really incredible top tips for for people. And I think, you know, having the knowledge is one thing, but putting it into practice practically as a geriatrician, as someone who's trying to look after the health of their parents or trying to promote health to their grandparents even, um, I think your book and and the content you put out there is super useful. So thanks so much for that.
Dr Kate Gregorevic: Yeah, and I think it's really important to break down this idea of health as this, you know, future thing. Like so many of the things that you do that improve your chances of longevity are actually better for your wellbeing in the present. And in a lot of ways, refocusing on wellbeing in the here and now, I think is a really powerful way to improve that longer-term health.
Dr Rupy: Yeah, absolutely. And I think, you know, I think when you when you get to a point where you have children and you're thinking about the future, you want to try and preserve as much of that amazing human experience that you have with your loved ones, we can start thinking about how the lifestyle interventions can fit within that picture of you being healthy and and full of vitality well into your 70s and 80s. And I think we need to reframe the way we think about aging to as something to look forward to rather than something that you have to deal with tomorrow, you know, a later date in your in your life. So.
Dr Kate Gregorevic: Yeah, and now that most of us can expect to reach very old age, you know, it's really time to completely disrupt the way we think about it.
Dr Rupy: Absolutely. Thank you so much for listening. Just to reiterate exactly what we talked about, squats, purpose, and plants. I think it's a really good three-word summary of the whole podcast. And if you want to find out more, do check out my guest on socials. You can check out all of her links on the podcast page, thedoctorskitchen.com/podcast. And also check her out on Instagram and the amazing book Staying Alive. It is an amazing manual for healthy aging, both today and the future. So it's definitely a resource for your parents or loved ones who are of that older generation. I hope you enjoyed listening and I will see you here next week.
