Dr Deepak Ravindran: I did not know enough about what else that I could safely offer in an evidence-based manner, in a scientifically acceptable manner, that patients would find acceptable to try and to get benefit from. And actually once I stepped out of that frame of reference that I must only give a drug or an injection, I actually found the evidence was there to say, well why should nutrition matter, why should sleep not just be an afterthought or something that you kind of talk as a aside when the patient's just about to leave the door and you say, you know, exercise well and sleep well and eat well. But actually they are probably has core to my consultation has the discussion about a drug and a side effect and injection and a to do or not to do.
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.
Dr Rupy: Today, I think I found my new favourite person. Somebody whose experience and intellect I respect and look up to and I'm confident that if you love listening to this podcast, you will love him too. And I'm going to put this out there to you. If you know anyone who works in the NHS, a nurse, a doctor, physio, dietitian, administrator, manager, literally anyone, gift them this book, The Pain-Free Mindset. Not just because pain is a silent epidemic affecting over 25 million people in the UK alone and we don't talk about it enough, but because this book is just as much about how we change our approach to health care from one of purely patient service to one of patient empowerment. And this eloquently written book describes how with an open mind, we can all create transformative change for patients and ourselves. So, who is this person? Dr Deepak Ravindran. He's an NHS consultant in pain medicine and what he describes as an upstreamist with a trauma-informed approach to pain practice. And as you'll hear today, he takes a truly holistic, trauma-informed and integrated approach to pain management. And he has a deep appreciation for the role of lifestyle, nutrition and the overlap between pain. He's got over 20 years experience in pain management and is the clinical lead in pain medicine at the Royal Berkshire Hospital in Reading in the UK. And he's also one of the very few consultants in the UK who holds triple certification in musculoskeletal pain and lifestyle medicine. And today, we're going to learn all about pain. The origins of pain, how pain is in your brain's interpretation of signals and how specifically in chronic pain, this can be affected by nutrition, emotional history, experience, childhood and many other influences. We'll also obviously going to talk about foods for pain, we're also going to talk about supplements and psychological therapies plus a lot more. And strap in because this is going to be a long podcast but fantastically useful for a lot of you. And I really do hope you share it with loved ones, friends and family. Do check out the newsletter, thedoctorskitchen.com, where I share recipes every week, plus suggestions on what to read, listen to or watch every week too. And the book, The Pain-Free Mindset, seven steps to taking control and overcoming chronic pain is a must read. I devoured it in literally about five or six hours from from cover to cover and it's one of those books that I'm going to reread as well. The pain-free mindset, you can get it in all good bookstores. It's not on audible yet, but I really hope that Dr Deepak Ravindran gets the chance to do an audible because it just needs to be as accessible as possible. And that's in the hands of publishers, but please do get a copy, gift it like I said, because it's one of those books that I think is going to be transformative for a lot of people. This is going to be a long podcast. I really do hope you enjoy it and please do give us some feedback on it. I always love to hear what people think. Give us a five-star review on Apple or Spotify. You can follow us on that as well. And it really helps spread the message and love on the podcast. But for now, on to my conversation with Dr Deepak Ravindran.
Dr Rupy: I read the book cover to cover. One thing I think was distinctly lacking was more about you. And so I I I finished the book and I was like, I just want to know more about Dr Deepak. I want to know where you grew up. I want to know what medical school was like for you. And now I have the opportunity to ask you all these questions on the podcast and give like extra depth to what is already an incredibly deep and well-written book. So tell us about like, you know, where you grew up, where you're from and and and how you got into medicine.
Dr Deepak Ravindran: Growing up was all in India. So I am from a town in Hyderabad in South India. It's one of the five now metropolitan cities in India really. And most of my schooling was in Hyderabad Public School. It's it is actually been the birthplace and a lot of the notable alumni include Karan Bilimoria as well as the Microsoft CEO and the Adobe CEO. So it it has those kind of illustrious alumni that it lays claim fame to. But schooling was, you know, pretty average. I think my parents really made sure that I was on the straight and narrow and and I pretty much did the usual stuff that kids do at that age. A little bit of a geekiness, I reckon, but at the same time, enjoyed my football, enjoyed my hockey. And I used to play a version of, I think it's a table game here that not many, I don't know how many of your listeners will be aware, but a lot of the Indians who listen, Asians will be aware, it's called carrom board. It's played on a square.
Dr Rupy: Oh, carrom. Yeah, yeah, yeah. I remember getting a carrom board when I was a kid. I loved it.
Dr Deepak Ravindran: It was, I was like totally chuffed when I came to East Ham here. I still have, I bought my first board here the moment I came there. I used to play the lot. I was almost a kind of local champion out there both for my association and it does and table tennis. So those were my kind of sporting passions there. And somewhere around, I think the year eight, my grandfather suddenly came down with cirrhosis of the liver. Now, he was a very religious person. He was someone who never smoked, never drank, all the characteristics and stereotypes that we thought of someone who got cirrhosis of liver, he was the complete opposite. And I found myself at that time being able to tell people, my family members and explain to them the biology of what happens when bilirubin goes this way, when when why do people turn jaundiced and what happens. And at that point, my dad was like totally focused on me becoming an engineer. In fact, back then in India, we had these kind of tutorials that would start where they'd send textbooks, and this is the 90s, mind you, and sort of late 80s, and he'd they'd send textbooks on the post, you'd have to read and write, and he wanted me to be preparing for engineering exams from year eight. And when my grandfather's illness happened in year eight and nine and my interest in biology came out, that was the first time they thought, well, you know what, we might have a possible doctor in the family. And that was probably one of my catalysts for taking the decision to go into or wanting to become a physician or a doctor because my grandfather's death was a mystery to my family as to how somebody could struggle like that. It turns out actually that he had been given a six-month course or a three-month course of tuberculous treatment. So it was finally put down to possibly anti-TB treatment that caused cirrhosis in him. But that was something that we fully didn't understand at that time as a family. And I think that was my first instinct or push to go there. And in in back in India, we had to make our decision at GCSE levels, whether we were going to a biology stream or a mathematics stream and engineering then onwards. And I think that's what led me to do change over to another place, very nice college called Little Flower Junior College. And and my medicine then, undergraduate medicine was in, I was very lucky to get into a tertiary institute in Pondicherry called Jawaharlal Institute. It's a very well-recognized institute now. It is one of the top five institutions in India to do your undergraduate and postgraduate medicine in. And I was really fortunate at that time to get the opportunity to study in that college there. And that's where I did my undergraduate. And when I came through, my choice was between going into surgery and I found a very inspirational mentor who actually showed me that anaesthesia and pain management could also be a very exciting field where there were the possibilities of more research and new findings. And at that point of time, pain management was very much about interventions. You know, could you do a celiac plexus block? Could you do one of these cancer and neurolytic blocks with local anaesthetic or with phenol or with some kind of really fancy drugs to give long-lasting pain relief to palliative care patients. The option of thinking about non-cancer pain, chronic pain was again something that was not on the presence of most imaginations at that time. This late 90s, there were no pain fellowships, the understanding of pain was very primordial in India when I was studying. And I think that was the early 2000s when I did my post-graduation in anaesthesia, critical care and pain management. And of all three, I found anaesthesia really fulfilling and satisfying, but it was pain management that I thought, you know what, the options of actually knowing so much, the research, the opportunities were expanding. There was just then some of the initial studies coming out from Irene Tracey in Oxford and a little bit of the studies thinking about pain a little differently to what I had learned in anaesthesia at that time. And even now in the UK, most pain specialists do come from an anaesthesia background. I think in the US, there is the opportunity for other specialities like neurology and neuro rehab and physical rehabilitation to enter pain management. But in the UK and even now in India, it were anaesthetists who went into pain management. And so when I came here, I finished my training in, it started out with the Yorkshire. So I came to the UK in 2003, started out in Yorkshire, and then after that got my registrar training in Oxford. And when towards the end of my Oxford training, I got the opportunity to do a fellowship in the University College London. So that's where my pain fellowship was in London and in Stanmore. And got to work with really inspirational consultants, clinicians who made me understand that actually there is so much more that is still undone in pain medicine. The way we were talking to patients, the way we were understanding the science itself was rapidly being revolutionised. And I think it was the arrival of some technologies like functional MRI, wherein you could actually see how nerve circuits were forming in the spinal cord and the brain that made the difference. You know, that actually turbocharged the understanding of pain medicine, pathways that were being used for processing signals of what we consider as pain. And I think that was my point wherein I said, you know what, the fellowship is what I want to do, but more than that, it was the springboard to say there is so much more that can happen in pain medicine and in this field that could be translated and used across so many other fields in core medicine itself. And you know, that's kind of been my journey from India through UK to where I am right now in the Royal Berkshire Hospital for the last 10 years as a consultant.
Dr Rupy: That's incredible. I mean, what a what an incredible clinical experience going to Yorkshire and seeing different parts of the country as well as UCL and Stanmore, which is a, I believe a centre of excellence for orthopaedics. Um and so you would have had incredible um mentors and and colleagues across there. I I I wonder because obviously your your book dives into a number of areas, but the the a thread that is uh quite apparent throughout everything is a a holistic approach to to pain management. And I'm wondering where that was instilled. Is that something that you came to a little bit later in your clinical career? Or is it something, I mean, you went to one of the top five medical schools in India. Was it something that uh the Indian medical education system already had an appreciation for? Was it quite separate from uh mind-body medicine, Ayurvedic medicine and other uh non-traditional or non-conventional uh techniques?
Dr Deepak Ravindran: Good question, Rupy. I I think a lot of that credit probably for that kind of thinking uh was laid down by my head of department for anaesthesia back in Jipmer. That was the medical school that I studied in Pondicherry, uh short in short form Jipmer. And he was the one who encouraged us to think a little bit more holistically always in terms, even though it was anaesthesia and you know, you could do the job of just putting somebody off to sleep and walking away. He was someone who always taught us to look at the person completely. You had to obviously assess and look at all organ systems and the person and optimize them for the anaesthesia that they were going to get. And he would encourage us to go the next day or the day after to make sure what the recovery was like and whether they were recovering. So I think the principles of actually looking at a person in a more complete fashion subconsciously was instilled by him. That was what he expected us as trainees to do there. Um, Jipmer in a way was also a bit of an island in the sense that the faculty there did not do any private practice in that sense. So there were a medical school that was very much about teaching to do things in a very fairly ethical and probably patient-focused manner at that time. You know, so there were not much of the corporate issues that can sometimes bedevil modern health care. And I found when I came to the NHS, that was an easier transition to me for me to make because the NHS is also fundamentally about patient care, about doing the right thing for the patient at the right time. So I think that was quite an easy transition to thinking and continuing the thinking about saying what's important for there. When I did pain medicine, of course, I came into it thinking I had my anaesthetic skills and as long as I had a strong heart and a good long needle, I could probably get to any nerve plexus in any part of the body and block it. You know, that's all it took. And and and it was rapidly within the first year of becoming a consultant in Reading there, it's a district general hospital is one of the second most busiest DGHs in the whole country there with the number of beds and the kind of variety of cases that I was seeing. And I was doing uh in sort of inpatient pain and outpatient pain. So I was not only an anaesthetic consultant, I was also doing inpatient ward rounds. So I was seeing medical patients being admitted with pain problems. I was seeing post-surgical patients with pain problems. And I was seeing complex patients coming for surgery, you know, people who were already on high doses of opioids or other strong stuff coming for surgery. So I was seeing the length and breadth of their experience that they would go through in a hospital journey, including outpatient and community. And I realized actually that if I had medicines, which were taught very well in a modern health care system, how to give drugs and how to safely give drugs and how much to give, and then interventions, which I learned in my fellowship of how many different kinds of interventions to do, I found that they were not that effective, they were not lasting that long, and it was not sustainable rapidly because by 2011, we were starting to get this pressures on the NHS to say these procedures are low priority, these opioids are causing problems, the gabapentinoids were being causing issues in some like drugs like uh nerve tablets were causing side effects. And I was finding myself that my skills, my core skills that I had were not really what my patients needed. And that was where I realized, well, these are the gaps in my training. Although I think I have been trained in very good undergraduate and postgraduate places, these were gaps I identified by 2012 that I did not know enough about what else that I could safely offer in an evidence-based manner, in a scientifically acceptable manner, that patients would find acceptable to try and to get benefit from. And actually, once I stepped out of that frame of reference that I must only give a drug or an injection, I actually found the evidence was there to say, well, why should nutrition matter? Why should sleep not just be an afterthought or something that you kind of talk as a aside when the patient's just about to leave the door and you say, you know, exercise well and sleep well and eat well. But actually, they are probably has core to my consultation has the discussion about a drug and a side effect and injection and a to do or not to do. And that's when I realized actually that's not the message I was taught. That's not the message my colleagues were being taught, and that's not the message we are giving to our patients. And I think that's where that holistic approach and now that sustainability is become such a modern mantra, actually a sustainable approach is being infused into my practice over the last four or five years really.
Dr Rupy: Yeah, yeah. I mean, just as a side note, uh, coming from an Indian background, um, myself, I got a lot of I told you so's from my family who are non-medical, right? So when I, when they were trying to suggest to me that, uh, food and spices and all these different sort of, uh, what I would have regarded back then as old wives' tales, uh, were important. I kind of brushed it off as like, you know, just some woo-woo stuff. And and now it's coming back full circle. Have you had those moments with your own family?
Dr Deepak Ravindran: It is. Even now, if I were to tell my father, or if I tell someone, you know, I think you can think about an anti-inflammatory diet. You know, this is my nowadays, in the last three, four years, ever since I've kind of got up and become this other person, I even my wife sometimes get irritated. No, no, this is not what I'm asking you what drug to take for pain. You can't tell me what to eat. And and I think my family back in India as well sometimes are a little bit more thoughtful when they now approach me saying, you know, okay, I know you're going to tell me about sleep and I know you're going to tell me about stress, but what I'm asking you is can which tablet can I actually take? So yeah, I I don't think that's going to leave us for a little while there. And and uh and I think that's the cross probably we'll have to bear because that's how society has been brought up in terms, isn't it? That's our challenge we have to is to tell other members that there are options that are as safe and probably safer than what we've always done.
Dr Rupy: Yeah, absolutely. And I want to circle back to some of the final parts in your book that I found actually the most um useful from from my perspective as a as a physician. Um but you you talk a lot about um certain philosophies in the book. I mean, you you talk about Descartes and the the entrance about um this uh the the impact of dualism on modern medicine. I wonder if we can just describe for folks what modern medicine is practiced based on, like the understanding and the separation of the body and mind and where that came from and and how that's uh that's Cartesian in nature.
Dr Deepak Ravindran: Yes, and thank you. I think that is a very, very important underpinning and you're right, it is a philosophy that we need to start moving away very quickly from. So, Descartes was the French philosopher, uh mathematician, philosopher, really awesome all-round gentleman from the 1700s. And he at that time was responsible for bringing on this theory. Now, at that time, the church was very much in favour of saying that the human body must not be touched on, must not be operated or because everything was one with God. And that was a very powerful philosophy and belief at that point of time. And Descartes came up with this approach and thought process that the mind is one with God, but the body is not necessarily one with God. And he also talked about his understanding of pain at that time, and this is this very classical picture that's there in almost every textbook around pain management that used to be taught about where you had this little boy with a small fire that was burning near his foot. And Descartes's vision of how pain was, was that there would be a fire, there would be this rope that would stretch from the feet, it would go through the back of the, he got the spinal cord part right. So he thought about this wire that has stretched through, goes into, and he suggested that there was a small part in the back of the head, what he called as a pineal gland, which is where the signal stopped. And his understanding was that because pain travelled in that rope, you could cut that rope or you could treat the body apart and find a way to either block, cut, numb that rope or wire, and then put it back together again, and there would be no pain because the mind is one with God, but the body can be treated in this manner. And that kind of Cartesian approach of the mind-body dualism was really advantageous because it allowed for the church to accept that as long as the mind is one with God, the body could be operated on, and that led to modern medicine really rising from there. You know, the fact that surgeons and other specialities could adopt that reductionistic approach of drilling down up to a cellular level, up to a genetic level to say what is a problem, and then the assumption was that it's a machine, so you could just put the component parts back together again and they would be fine, they would be same. And I think it was good because it allowed for a lot of advances that we see in modern medicine to be ready now. But it has also had its significant disadvantages and they are now in the last 30 to 50 years, we are beginning to know that that kind of separation is probably a flawed approach, which has led to a lot of over-medicalization maybe, because we're always stuck in a model of which structure is it that a particular pain is coming from without realizing what else could be contributing to it. And we've now come to a point wherein we've realized, like there are things like social determinants of health, we realize what are the other factors like epigenetics, you know, what are the factors that trigger our genes, and those are environmental, and we realize that all of that also contributes to our health, to what is considered as a threat and to what is manifested as pain, that doesn't sit well with a Cartesian model or his reductionist approach. So I think we are in various pockets of society talking about moving away from this mind-body dualism, which is very artificial, which is flawed and leads to poor policy and decision making. And it's time to probably firmly bury it and put it behind us and actually say the mind-body dualism is wrong. Now that we understand the neuroscience of how things happen and how pain is processed, we need to even firmly move away from there and look at the person as a whole in what I call as a trauma-informed manner, and that should be the way forward for modern health care itself.
Dr Rupy: Yeah, I think I think that's a a great way to frame the rest of our discussion about how the traditional model of dualism is flawed uh and uh what the origins of that are. Just as a side note, I always wonder whether that Cartesian approach was really a work around for Descartes to get around the the the church. Yes, absolutely. I agree. I think So I can keep everyone happy. You can have the brain, you can have, you know, you can have the mind, that's, you know, that's with God, but let let me operate at least on the body. Uh and and that's influenced how we practice medicine ever since, you know, it's I I always wondered that.
Dr Deepak Ravindran: I I agree and I think that is absolutely right. You hit the nail on the head there. Different kind of nail.
Dr Rupy: Different kind of nail, yeah. Um so before we we talk about uh pain, I think we should uh talk about no this concept of nociception or the the the biochemical process of nociception and the interplay of intero and exteroception uh on nociception as well because um the definition of of pain has recently been reclassified as well that you've written about in the book. So why don't we start there and then we can uh branch off into other subjects.
Dr Deepak Ravindran: Absolutely. So, um I think the first thing to start off is the definition of pain itself. So, it has been a very cosmetic change in the definition that was proposed by the International Association for Study of Pain. You know, they did their first definition in 1979 and I think they've now revised their definition in 2020. There is very little change in the actual definition in terms of words, you know, just a mild cosmetic change. But what is most important uh is their sort of what they call the supplementary notes. And they had about six points where they talk about it. And for me, the second point where they said that there is a difference between pain and nociception, which is very vital. And to me, I think that is a message which I've been trying to get out to the general public and I hope your listeners, if I can explain it well today, will also take away because that I think is the core to what my book is based on and that I think is enough. If people can accept and take that on board, that should give them the hope that there are so many other things that they can do for their pain than what they have been doing up to now. And what I mean is when you have an injury, when you have a fall, when you have a fracture, when you've broken some bone or you have a heart attack, there are chemicals that are released at those nerve endings which are closest to the site of injury. Those chemicals are released and then they travel in those set of nerves there. So there are no pain pathways. They travel in the same nerves that are sending every other signal as well from that part of the body. And those signals then travel up to the spinal cord where they then either get amplified or modified or dampened down, and then that remaining signal travels up to the brain. Now, the arrival of that signal, that is called a nociceptive signal, and that process of chemicals being generated and being transferred in these nerves up to the brain is what is called nociception. So that means nociception is only referring to that condition where you have chemicals being released in response to a a stress, a threat. It can be a physical injury. And these days we realize that you can have that external, so you can have that uh information coming from the external side, which is what is called exteroception. So when you see something that is frightening, when you feel something that's hot or injurious, when you have a chemical or a physical injury, then that all releases nociceptive signals. But when that signal reaches the brain, the brain then has to process that signal and it and it and it looks at it and what it has got, and that is the fantastic thing that we've realized now, is that the brain is actually a prediction machine. Now, it actually is almost the understanding of the brain in the last 10, 15 years is what's led to Google's Alexa and Siri and all of these fancy algorithms that sit in our kitchen doors and islands. And it talks about what happens when that signal arrives. It's already got a prediction model inside and it compares it to its previous experiences of having received such a signal, the context in which that signal has arrived, and then it has to decide in a microsecond, does it have to institute a form of safety and protection or does it compare it to a previous model and say, you know what, this has already happened before, it's nothing to be worried about, it's not unsafe or dangerous thing. And actually then the prediction model suggests that you don't have to do anything much and therefore no protection mechanisms register. So all of that processing and prediction mechanism is done in a flash of a second and if the brain decides that it needs to protect you, then that is when the experience of pain will arise. So when somebody complains of pain, the intensity and severity of pain is very much a function of how that signal has come, how much protection the brain has decided it must provide and how it then institutes that protection. So, pain, the experience of pain is then automatically different from nociception, which is the signals that is coming through. Now, in some people who have had a fracture where the injury is acute, the nociception is significant and is almost the entire part of the pain experience. But when you have chronic pain, when you have pain that goes on for months and months, when you've had a back problem that has been on there or a knee problem or a migraine or irritable bowel, then in those situations, what we are now understanding is that there is the pain experience because the nervous system has stayed sensitive and it feels that it needs to constantly protect and that's where the chronic pain can persist from. The amount of nociceptive signals may not be that much. So I don't want to tell, make your listeners feel, you know, often at this time when I say this, people say, are you saying it's in my head? And and actually, no, it's not what I'm saying. It's not that it's in your head there, but the signal processing is happening within the spinal cord and the brain, and they are unfortunately located in the skull. So that's where the processing is happening, but the signal is very real, the indication is very genuine. However, at the end of the day, somebody has to protect you. And that patient needs protection and that brain, if it thinks, sometimes in error, that protection is what is needing to be done because that's what it did the first time, then that's the same model it'll go back to. And and that is why we need to understand that difference between pain and nociception because that nociceptive signals can respond very well to a drug or an injection. But when you realize that often things are in combination or the pain experience is a lot more, that's when you have to bring in other ways of dampening the system down. And probably the one thing that you were asking me was introspection and extroception, weren't you? The last bit there. So, introspection is when the signals actually can come from the inside. So, if you only if I ask you to think about it now, will you realize that your bottom is sitting on the chair, that your feet are on the ground. Otherwise, this information is coming all the time. There's information coming from the intestine, from the bugs, from the microbiome all the time. But the brain has to make that constant decision on which one it allows in, which one it does not allow in. And those decisions on what it allows in is based on what it thinks it needs to protect you with. And I think that some total of the information from the inside is introspection and the some total of the information that comes from the outside, whether it's through touch, through the five senses, vision, taste, smell, is extroception.
Dr Rupy: That's fantastic. There's a few things there that uh I think are going to be really useful for the rest of our conversation. So there's acute pain and chronic pain and I I guess most of what we're going to be chatting about today is going to be in the latter chronic pain category, which is pain that persists for generally over 12 weeks and can have a number of different um instigating sources. And then uh you've also, one thing I think uh is one of the myths that you wanted to um uh make sure were were completely addressed about pain pathways. And this is something that I was taught at medical school and I still had in my brain that, you know, you have specific pain pathways. Uh and you know, but but but really what you're saying is it's it's nerves and the experience of pain is highly personal based on a number of factors. And you've got this wonderful diagram in the book actually about the different elements that can change one's personal experience of pain. Um and I think that's the other thing as well that comes across very apparent in the book is that pain uh experiences is very, very personal. It's not to say that it is all in your head or you know, this is psychological and you know, you need to think, you're being anxious. It's it's a uh your experience is the product of the collection of all your experiences up until that point. Um and there there was one example that I think that really illustrates the the experience of pain very well and albeit it's to do with an acute scenario, but I think it it it really explains a lot about what you're saying. It was the the uh the case study in 1995 of the gentleman who uh who had a nail go through his foot. Do do you want to mention that? I I thought it was a wonderful illustration of what you've just talking about.
Dr Deepak Ravindran: It is a stock uh slide and and and picture that I talk about and I always say how builders have contributed so much to understanding of pain. And and uh and it always is something when I talk to members of public and I tell them about this case, they are astonished that this can happen. And this is reported in 1995 as you said, Rupy. So this was a story of an anecdote of a builder who jumped off a work building site and landed on a 5-inch or a 4-inch nail that went right through his boot. And at that point of time, according to the case study there, he just collapsed on site. He was writhing in pain. He could not be controlled as he rolled from side to side there and he was visibly in distress because of that big nail that was protruding right through his boot through and through from the bottom up there. So the ambulance drivers could not control him on site. So they took him to the emergency department. It's a UK-based case study as well. And in the emergency department here, none of the emergency department colleagues could do anything, you know, gas or whatever did not work. So the decision was made to say that, okay, he needed surgical intervention, he needed to go to theatres, we need to sedate him with a general anaesthetic and then we need to do what is needed to sort his leg out. And they took him to theatres, got him off to sleep, took out the nail, all clean and sterile there, took out the boot and they got ready to operate or look at his skin wound. And what was astonishing for them was that the nail had gone between his big toe and his first toe. There was absolutely no evidence of the nail having caused any physical injury to his skin at any point of time at all. Now, when he woke up from there, that part of the case study doesn't go there, but as a pain physician, as any physician there, none of us would deny that he was not in pain. That was very much his experience. And if I have to explain it from the way I have talked about pain in the book there, is even in acute pain, the decision has been made by the brain that it needs to protect. And if it is going to predict that something like that that is sticking through the boot, the nail that has come from below and is sticking through the boot there, its prediction model was that it must be painful, it has to protect you, it would have to ensure that you don't make any movements, so you lie there, call for attention and ensure that that protection and intensity of pain stays on until the problem is resolved. With now our understanding that the nail never caused any physical injury, it's clear that his vision, so his exteroception provided him the information that protection needs to be instituted. The prediction model was obviously wrong, but it still was protective enough because that's the purpose. It has to make sure that he survives and that was what is important. So that study to me actually, when I tell patients, is exactly as you say, although it is an acute pain scenario, it is how that whole prediction model is formed. And at that point of time, as far as he is concerned, he will always remember and there will be a nerve circuit that would have been formed, you know, fired and wired together at that time that would have told him the next time you see a nail there, think about it, but it is better to probably institute protection because you do not know if the next time is going to be the same as the first time. And that could very well set the stage for him being a little bit more worried the next time he goes and is about to jump off a site. Some of that is natural worry, but some of that is can be at an extreme, lead people to get more worried about what the signal might be. And this worry is a reflection that the nerve circuit is formed and is ready and wired up and ready to protect him the next time.
Dr Rupy: Yeah, I thought it was just such a a lovely illustration of the predictive and protective mechanisms within the brain that you you mentioned. And you mentioned just there actually about how uh neurons that fire together, wire together. And I think some people might have heard that before. I didn't actually realize it was referred to as Hebb's law. I should should do some more research on that. But I wonder if we could use that as a jumping off point um toward uh how people's experiences of pain differ and with specific regard to something that I'm teaching myself a lot on at the moment, which is adverse childhood experiences or trauma uh and and using the the builder's example again, you know, it wouldn't have said it in the case study, but I wonder if he has had an incident where nails have come near him or actually uh uh punctured him or he's had a previous injury that that actually led to that um vivid experience of pain even though there wasn't the uh stimuli uh or the the the genuine uh injury uh to um to instigate that.
Dr Deepak Ravindran: You're absolutely right. You know what? That is a fascinating insight, Rupy, because I myself, you know, when you tell me now, actually, I realize it could be while I had said that it would have prospectively fired it up, but you're right, it might have actually been a retrospective, you know, he might be very well responding to something in the past as well. So yeah, no, that is really useful insight in that point there. So, it's quite a very accurate place to actually frame that conversation as to how far back that firing and wiring together could have happened to keep protection on. And as you said, adverse childhood experiences literally has turned around my way of viewing medical health care itself. I came across this study in 2016, you know, until then I hadn't realized that this has been around for 20 years. And even now, in 2017 or 18, when I tried to tell my colleagues in secondary health care that we should be paying more attention to this, we should be thinking about getting our organizations to be trauma-informed because these are going to be very vital in how we look after our patients when they come to hospital, I still didn't get the traction. Even now, I don't think the traction or the understanding is there. And I think it's a combination of factors. And I think the most important one is medical physicians are just not able to get their heads around the fact that a lot of what we've studied may actually not be fully relevant if you don't understand the whole person. And the second part, I think is systems and policy makers and organizers, organization heads do not know how to actually grapple with that information and how do they actually address it in a safe, consistent manner. I think that combination has meant we've been slow to take it on board and run with it. But I think it's very vital. So, adverse childhood experiences for your listeners and I maybe I think you have done probably a couple of pods on it as well there. Um is for pain especially is massively important because that wiring and firing of neurons is constantly occurring in us each time. And this is something I realized that actually when we uh are born, we were told that actually our brain develops as we grow. But it's the reverse. We are actually born with far more neurons and connections than we actually need. So the first three years, the first thousand days, and then at critical phases of time, like at the point of puberty transition and at the point of transitioning to adulthood, these three periods of time, the first thousand days and around the 8 to 12 year mark and the 16 to 18, are periods of intense activity where those neurons and synaptic connections are pruned. And that pruning is going to depend on what the brain's prediction mechanisms of protection and threat are going to be. So if an organism, a person during those periods of time is exposed to a persistent amount of any kind of stress, whether that is environmental or food or you know, whichever way, it is going to influence how these neurons that have been firing and wiring together are broken up and rewired and fired together again. That means these are all critical points of life as well as the whole year less than 18 year period that you can have this changes embedded and it is difficult to know whether those changes can be undone later. What we are realizing in a hopeful manner is that it is possible the neuroplasticity or the fact that this nerves that wire together, fire together can be constantly changed throughout life, maybe it's a little slower as we age, but that aging process doesn't diminish the ability of our neurons to fire and wire and learn again, means that those traumatic experiences are not just about adversity in childhood, it can be adversity at any point, you know, it can be divorce, it can be bullying, it can be a road traffic accident as well. All of that can change how the neurons fire and wire, and that's where the hope is that we can also make them fire and wire for the better, whereas up to now, they have been kind of doing it in a maladaptive, sometimes overprotective manner.
Dr Rupy: Yeah, absolutely. One of the things that I think was um pivotal for me getting to the root cause of a lot of patients' issues um when when practicing general practice is uh doing something called a timeline. Um where you look at any instances throughout their whole period of life where they might have had instances of trauma. And like you just said, trauma comes in many different forms, whether it be illness, whether it be bullying, whether it be uh a whole host of other psychological as well as physical insults. And one of the questions you have in one of the questionnaires, you've got many questionnaires and I think they're they're brilliant because you can score and they're they're a lovely uh qualitative as well as quantitative measures of people's um health status. But one of the one of the questions uh that really uh appealed to me was, when was the last time you felt well? When was the last time you felt healthy? And I think just being aware of when that was gives people an understanding of where things might have gone wrong and what was what was going right up to that point as well. What was the instigating factor? Um and and I wonder how your colleagues um would would approach that as well. Is that something that they feel that they can get on board? Is this something that you're struggling to even today in 2021, try to is this something you're struggling to try and get into mainstream practice?
Dr Deepak Ravindran: In in my team in Reading there, I'm glad to say that at least that is almost the way we approach our pain consultations both in the community and in secondary care. Uh we start off by actually actually saying, okay, when is the last time, especially with chronic pain, we say, when is the last time you actually felt well and did not need any pain medicines and were working full-time and being fully productive. And that often gives us a bit of a starting boat to say what else could be feeding into this chronic pain and not the drug or the injection that I'm going to offer there. Is it mainstream and is there? It is a challenge. partly and I think it's because of the same things that I said, Rupy. A lot of my colleagues, uh you know, as a pain fellow as well, all of the things that are written in the book are not things that we are taught or asked to read about and be aware. The focus of our training in medical health care generally in undergraduate and postgraduate is around what are the treatments we can do to cure the problem. So it is a challenge because then to take on these things, you have to start early enough. So I really feel that the present bunch of undergraduates that are coming through are receiving that kind of holistic approaches much better. They're getting that communication skills of how to use that in practice. So I feel that this generation that is coming through is getting that kind of training there. But the older generation, our age group of the 40s, I suspect it and this may be provocative and maybe to some of your listeners there, each one will have to probably find their epiphany moments on their own. There has to be some kind of a mini point at which they would change or they would be willing to take this on board and take it there. Otherwise, if their life is fairly happy, a healthcare professional life is running fairly happy on autopilot doing what they're doing and it's okay, then they won't see the need to change. You know, their neurons have fired and wired together for them to now unlearn and relearn something has to be some kind of a decision barrier has to arrive, personal or external.
Dr Rupy: Yeah, I I I agree. I think um and this is where I look back at when I got ill myself uh as my own epiphany moment and that happened right at the start of my medical career over 10 years ago now. And I don't think if I had had if I hadn't have had that event happen to me, I think I would have been coming to this way of looking at patients more holistically. Um a lot later in my clinical career and it would have been something I would have been highly skeptical of. But what is nice to see is the new cohort of students um coming through medical school are a lot more appreciative of lifestyle medicine and you know, we were talking about before about your work within lifestyle medicine and patient groups. And I think even those who haven't had personal or family experiences that have required uh taking an orthogonal approach, a lateral thinking approach to to medicine are coming around to the idea of um these wider array of tools even if we are still waiting for that core evidence base behind them. Um and the concept of over-medicalization and polypharmacy, I think are well uh recognized within the medical um field. So, yeah, hopefully that there is a there is scope for improvement there.
Dr Deepak Ravindran: It is. I think a lot of times, uh I tell this to, you know, pain patients as well, and now there is this uh sometimes overzealous approach to reduce uh over-medicalization by de-prescribing or reducing medication use. And I tell my colleagues who who want to do that or sometimes pharmacy colleagues who reach out to me saying, we need to reduce the amount of opioid prescription for these patients there. And actually, I'm I'm a little cautious. I I actually tell them, look, fundamentally, if you're asking a human being to change their behaviour, change their support systems, we need to make some things convenient, easy and provide them an alternative framework that is equally appealing for them to change it from one framework to another. If we don't create that framework and safety net to move there, then it'll be very difficult for them to just come off the medicines and using the threat of saying these drugs are dangerous and these drugs are harmful, that kind of negative strategy doesn't really work at a human psychology level. It doesn't work in the long term. Some people might be feeling anxious and come off the drugs, but if they don't have anything else to go to easily, they are going to feel trapped, vulnerable and they're going to say, you know what, at least this was better because I knew it was doing. And we will choose convenience and short term, you know, that's what organization of behaviour says. We will choose convenience and short term because we are unable to think in the long term at a, you know, sustained period of time, especially when we feel things like pain and distress.
Dr Rupy: Yeah, absolutely. I think that that's such an important point to make and it's uh we have a parallel within um psychiatry as well. I think there's a demonization of uh certain pharmaceuticals, antidepressants that are very, very useful for a lot of patients. But I think there's, you know, people feel that they shouldn't be on them or they're demonized for being on them because they're not doing enough in the other parameters. And what you describe so eloquently in your book is this blended approach where we can appreciate all these different tools that are relevant for different people at different stages without any judgment. Um and uh and that comes up with the mindfulness-based therapies as well with the non-judgment approach to things. So I think, you know, it's it's a very good point to make. Um we should talk about uh gliopathy in chronic pain. Um and uh and perhaps even some of the the newer drugs in in that respect as well. Um why don't we talk about the the the the sort of the inflammation aspect of of chronic pain and and and how that is relevant?
Dr Deepak Ravindran: Well, that is a probably another of the game changers for me because in terms of options now to offer and talk to the patients, I think it is an exciting place. The challenge that we all will have is to overcome that stigma or that perception that these are airy-fairy, woo-woo stuff when actually the core evidence for them is starting to, as you say, emerge and it's getting better as time passes by. The fundamental assumption is, again, when I talked about nerve signals travelling along the neurons, and we talked about the signal that comes from an area of injury to the spinal cord where I said they are amplified or dampened or modulated, we often did not know what that meant, you know, who was doing the dampening and the amplifying and modulating. And then in the brain as well, we always thought that the brain was just a whole bunch of nerve cells, and we were told in medical school that there are these cushioning and buffer cells called the glial cells, which just do the job, you know, they just buffer and support. What we are now understanding and we have come to realize is that these buffer and support cells, these kind of gatekeepers and housekeepers are called microglia. And they are not just the buffer and support cells, they are actually representatives of our immune system. So they are part of the immune system that is there in all our bodies. And during our development, when we are growing up as a fetus in our mum's wombs, at around the eighth or ninth day, these representatives of the immune system move away and enter into the spinal cord and into the brain where they stay. So they have a really long life. So they are not only just supporters, but they actually are the nourishers. Now, an author called Donna Jackson Nakazawa calls them the angels or the assassins. And in my book, I kind of refer to them as the Dr Jekyll and Mr Hyde. So, while they are there, they are present in every junction. So the we used to think that when a signal of, let's say a a nerve signal that's carrying nociceptive input or a touch or a heat input arrives at a junction, it jumps into the next junction and the signal travels up. But and we always talked about that junction being just two nerve endings, you know, a two sum. But now we are saying that it's actually a three sum. At each of these junctions throughout the body, there are these microglial cells that are like a Dr Jekyll, they are like the traffic policeman, they are keeping a constant lookout for the junction, they are dampening some signals, they are amplifying other signals. And therefore, the question is, who is giving them that information that they decide how they do it. And what we realize now is that these Dr Jekylls have a camera. And their surveillance camera is looking out for patterns. These patterns can be and these are called the amps that, you know, for technical names, the associated molecular patterns. And these patterns can be triggered when you eat wrong food or inflammatory food or highly processed food, when you have threats, when you have surgery, when you have antibiotics, when you have viral or bacterial infections, when you have cancer cells, these are triggered. When that triggering happens, this Dr Jekyll then becomes a Mr Hyde. And they in the process of trying to protect and reduce the danger that's coming from all these external threats, it can end up causing collateral damage to the junction itself. And so this kind of low-grade inflammation at a junction is now being seen in many parts of the spinal cord and in many parts of the brain as well. And and when it occurs at certain hubs or major junction or traffic points within the brain, like there's an area that processes fear called the amygdala, there is an area that processes and stores memory like the hippocampus. When these areas also get affected, then that's when people start to get neuroinflammation that is low grade and that can have impact. So even within conditions like long COVID, in other conditions like Alzheimer's, and this is seems to be across the board in dementia, some forms of diabetes, we are seeing evidence of this kind of neuroinflammation that's due to the glial cells not doing their job properly or actually doing their job a little bit overzealous and therefore causing collateral damage that is unintended but nevertheless an issue that then presents as symptoms. Chronic pain is now considered to be a problem that could be because of glial-related inflammation happening in many parts of the spinal cord and the brain. And that means that the new targets we are looking at, which is being in research, whether those are drugs, whether those are non-drug strategies like meditation, yoga, mindfulness, nutrition, nutritional targets, sleep, all of these are ways wherein the Mr Hyde can be moved back to becoming a Dr Jekyll again. And that can happen if the systems are put into place. So that is a really good thing. If we get drugs that can also move the signal and get the glial cells back to becoming Dr Jekyll, really well and good. But we have got other non-drug strategies that seem to be doing it. So we just need to find a way to double down and help them do it.
Dr Rupy: Yeah, I I that's so well explained and I love the uh the sort of image I have in my mind of all these different uh elements of interventions that we have, whether they be drug or non-drug, psychological, etc. And they all offer marginal gains and improvements. And those marginal gains, in some in some cases, huge gains, but let's just say they're all marginal gains, that collectively leads to a quite a pronounced response as you've had experience of in your in your clinics as well. Um I've been staving off this conversation because uh I I otherwise we would just spend the whole time talking about food, but I really want to talk about food. Because I thought it was one of the the the things that obviously attracted me initially was, wow, okay, you're talking about food in such a passionate way and you understand the gut-brain axis, the importance of your immune system, uh how neuromodulators and neurotransmitters are created in the gut and they have direct and indirect impact. So let's talk about food. Uh so we could spend like another couple of hours talking all about food, but we we're not. We're we're going to give some top line um some information. So the microbiota and the microbiome, the genetic uh accumulation of all the uh microbes that we have largely in our gut, uh is something you're clearly very interested in. Uh how can we modulate this population to have the impact that you just mentioned on glial cells as well as general inflammation that appears to be related uh to chronic pain in particular?
Dr Deepak Ravindran: A lot of food for thought here for your listeners now. Healthy cheese, man. Um but uh this is again the target I think we should be doing a lot more research on trying to use nutritional targets and nutritional strategies more actively to manage chronic pain. It's something that patients are willing to take on board. I've found so many patients accepting that conversation. You know, they may have uh restrictions or have their beliefs and their experiences with drugs and side effects or interventions. But when it comes to food, they see that as a tangible thing. You know, sleep and physical activity, they may have other reasons for not being able to do. But food is always something that they are interested. It's a tangible set of advice that we can give. And I think like yourself, there is enough evidence to actually look at broad good advice that we can give around nutrition without getting bogged down into the controversial aspects of some parts of nutrition or nutritional strategies and advice. You know, so I stay at a top level as well when talking to my patients. And that all comes from our understanding that as I've explained to you now, sort of to the listeners as well, that there are these representatives of the immune system throughout the spinal cord and the brain that are constantly monitoring the traffic and helping the brain to respond, predict and protect. This immune system, the rest of the immune system that's not there in the brain and spinal cord, 80 to 90% is actually around the, you know, the gut, around the intestine. And that means that this immune system is present in that area for a reason. And to me, that was fascinating to understand because it realized to me that the introspection that we feel, you know, when we talk about all this information that the brain is feeling from the inside, one of the biggest places where that information from the inside is coming is this huge tract that we have right from the mouth all the way to the back passage, which is essentially just a single cell thick in most places that separates the rest of the body from the external part. You know, although it's inside us, but it is still relatively outside and it's just one cell lining thick that separates all these bacteria and the microbiome that's there inside our intestines in various parts of our, you know, food passages. And that made me think that, well, that is a good enough reason for our territorial army of the immune system to be mainly located along the single cell barrier because it's got to constantly keep monitoring that environment for any threats. So, what we then eat is going to be potentially perceived as a threat by the immune system. And if it receives such information, which it does, because it's only a single cell thick, there's now suggestions that some of these immune cells stick their fingers out into the sort of lumen of the intestine and are picking up small talk that's happening between the various microbes and are making predictions and decisions on protection and threat. And the immune system in the gut has a sort of six or eight-lane highway through the vagus nerve and this nerve is directly connecting the brain to the gut. And that's what forms sort of the gut-brain axis there. And the vagus nerve is a supercharged bidirectional pathway. Now, again, something that I learned in medical school was that the brain tells the vagus nerve and the vagus nerve kind of picks up all this information from the rest of the body. And I always understood as a unidirectional, it's a one-way traffic from brain down to the gut. But now we understand it's a two-way traffic. There's constant information going to and fro. In fact, more information is going from the second brain in the gut back to the first brain within the skull. And actually, the second brain is making a lot of that information. So, two two more cheesy things to say is what happens in the Vegas doesn't stay in the Vegas. It gets involved there. I credit that to John Cryan who made that quote there. And uh and the other thing is the whole concept of gut feelings is actually very well understood now because often the gut and the immune system around there is the one that makes that predictive decisions first based on which our brain then takes that decision and decides if it needs to protect more. So, all in all, influencing the immune system through the gut is a very powerful mechanism. And we now realize why some drugs, for example, painkillers, medications, pain medications, do have a negative influence on the immune system and can be pro-inflammatory. There are other drugs as well that have been known to do that where they, you know, spoil the lining of the single cell and make it more vulnerable to damage from the other unhealthy or bad bacteria and microbes that are in the gut there. And so modifying what we eat could potentially be a way of calming the immune system down and that can potentially calm the nervous system down and move the inflamed glial cells from their Mr Hyde role back to a Dr Jekyll role. So that's that's the way I tell my patients and I hope your listeners as well that why doubling down and looking at nutritional strategies and anti-inflammatory diet, good hydration, a top level of reduction in processed foods, eliminating other ways, you know, maybe dairy, maybe gluten, maybe maybe other forms of sugar, could very well be a strategy to calm the immune system down in chronic pain and that can have a downstream effect of calming the nervous system down and you'd therefore have one strategy of reducing a percentage of your pain. It doesn't prevent you from taking other strategies on board, uh but it is definitely a useful strategy. And the other thing that has been quite useful is the time of food. I am quite interested in that whole concept of intermittent fasting and giving your immune system in your gut a certain amount of time every day to do its own MOT. You know, if it can be given anywhere from 12 to 14 hours that you can give some peaceful time to your gut to just do its self-cleaning and not load it with snacks and junk food all the time, then I think that itself is a good self-healing mechanism you can provide your immune system to.
Dr Rupy: Walter Longo, who uh is credited with the fasting mimicking diet. He's been on the pod in the past. Uh and we're we're also going to get Satchin Panda as well, who's brilliant. Um who's done a lot of work on on animal studies but also translated that into human research as well. Um and I think a pragmatic strategy is a uh a period of time where you do not eat around 12 hours, 12 to 14 hours, fantastic. I mean, I'm currently fasting at the moment uh because I I didn't want to rush my breakfast before having the podcast. And so I do a gentle fast for a few hours and I might break it at like 11:00 a.m. and then I'll stop eating tonight at about 7:00 or 8:00 p.m. So, you know, it's for for me, it fits into my lifestyle and I think it's, you know, something that people can can personalize to to what's convenient for them. Um and I think the foods, what you're basically describing there is a very Mediterranean style diet with lots of variety. You talk about variety in the book as well and the importance of diversity for your microbes, colours, whole foods and minimal processing. Um the gluten and dairy uh exclusion for a few weeks, I think in some circles is controversial, but I think particularly when you're dealing with patients who have tried multiple uh interventions and are and are in significant amount of pain, a trial for six weeks is very reasonable as long as they're happy to try something. And I think from my personal experience, and I only personalize these sorts of diets when I when I'm, you know, dealing with patients one-on-one, um they have been effective in in some cases. Uh absolutely, whether that is placebo or whether it's uh you know, a genuine impact on inflammation levels or they have an intolerance. I think these are strategies that we need to be open-minded to. Uh and I commend you for talking about that in the book.
Dr Deepak Ravindran: Yeah, I you know, again, my feeling is that if we are going to be talking about sustainability, then what what difference would it make if it is a placebo? Because again, the research around placebo and I talk about it in the book as well is is placebo is not just the dummy pill that again we've been taught in medical school or a sugar pill. It's supposed to be the entire meaning response. You know, what does it mean to actually see a healthcare professional who trusts you, who you value, whose opinion you trust. And if you can get that kind of response from a clinician, be it primary care, secondary care, and that leads to a change, then and if that change and that decision and what you're giving is of economically low cost but still value, then that is would be acceptable. And I think that's where we also need to talk about that placebo response is how can we actually harness the placebo response and the placebo effect to make good useful medical decisions because on one hand, a surgeon could say, well, yes, my knee arthroscopies or my shoulder arthroscopies I did, which now are shown to be no better than placebo. And that's why uh many people are not getting approval for such surgeries to be done because it shows that it's no better than placebo. One of the surgeons came and told me, well, it is good, it's you know, so what is placebo, the patients are getting better, so what? And my thought would be, well, yes, sustainably, you're absolutely right. You you are having a trusting relationship, you have created a ritual, you have told the patient that you're going to clean out their knee and that's given them six to nine months of relief. Super awesome, you know, fantastic. As a placebo response, excellent. But if the system is saying that that's costing so many pounds of money, that's taking three, four weeks or six weeks for a person to recover, and that's incurring so much uh anguish and worry for the patient in the run-up to surgery and the recovery from surgery, then it doesn't become a sustainable option. And that's where I would say, if you can achieve the same kind of placebo response and healing response with lesser uh, you know, cost but the same meaning response, the same trust, the same outcomes, then that's what I think we should be encouraging people and telling them that it is possible to do it with food, it's possible to do it with other strategies that do not cause harm or keep you away from work for X period of time.
Dr Rupy: Yeah, absolutely. And you know, this brings me to a point that I don't think I make um enough on the podcast. It's why I love talking to NHS physicians with experience because I speak to a lot a lot of people from different backgrounds in different countries, including America. And obviously, God bless the Americans, love them. They're fantastic, but they don't have a deep appreciation for having to deal with the cost-benefit ratio and uh the universal health care system um that you've eloquently described there. You know, we we have to make pragmatic decisions about management and the uh the risk of harm as well as the risk of uh draining the system of money such that we can't spread the um the health care uh providence, you know, across the population. So I think that that's a really, really important point. Um and if there are pragmatic, effective means to treat people, be it with food, be it with psychological therapies that are cheaper, incur less uh side effects, uh or less risk of side effects, um then yeah, it's definitely something that we have to entertain uh more seriously.
Dr Deepak Ravindran: I mean, I I write in the book as well towards the end, you know, when I ask patients to make a plan of, you know, how they're going to sustainably manage their care, because the reality, like I I wrote the book keeping our NHS in mind there, but it is applicable to most health care systems across the world, is really that concept that everybody's saying, oh, we should self-care more, you know, we should teach people how to self-care. And I think that's where you're doing such a fantastic job with, you know, with your culinary medicine, with the way you're setting up uh this way of actually teaching the doctors on how to cook and show that nutrition can make an effect there, because what we've traditionally done is a model for for the lack of again, any comparison, a metaphor I talk about in the book is we've always used a a DFY model, you know, done for you. You come to hospital, you lie down quietly, we'll do the surgery, we'll give you the drug, you follow our instructions, everything. And then in a very short space of five to 10 years, we are telling them DIY model, do it yourself, you know, just look at a list, do a copy a paper, look at four exercises on a piece of paper and carry away with it. And actually, there are approaches like the pain management program, which is like a DWY, done with you. You know, you sort of you teach them how to do it, you take them through it, you start off the process and you take them there. And what we don't do as a health care system is we don't provide enough funding and recognition for the DWY, which is a very necessary bridge to get people from DFY, which is apparently becoming unsustainable for any health care, including NHS or there, to DIY, which will also become unsustainable for the patient because you're asking the patient to then cough up their hard-earned money, but you're not giving them the skills to do it or where to go and do it. And so I think that is a necessary step and I really applaud you because in terms of doing the, we need more of that kind of work wherein we empower our health care colleagues as well as our patients with almost a handheld strategy to make sure they're comfortable and then let them fly.
Dr Rupy: Yeah, you know, this is what I was referring to actually at the start of the podcast, which was perhaps the most important takeaway for me was this uh categorization and it's something I haven't been able to articulate as well as you've done with the the the three uh the the acronyms or the um the abbreviations, the done for you, done with you, do it yourself models. So I love how, you know, medicine currently and certainly uh my experience of it over the last 20 years has been you have a patient in front of you and they are passive in acceptance of drugs and surgeries. You have some element of partnership where you have a physio or you have a health coach or you have someone supporting you through your journey. But the patient-led side of things is something that we've gradually eroded, I think, over the last 50, 60 years as the importance of uh pills over plates or pills over, you know, insert intervention that you do at home, um has taken precedence. So I think restructuring that such that there's more symmetry across them is the overarching goal, I think, of health care if it's going to be sustainable in the future. So that I just thought that was just such a wonderful element. It's right at the end of the book and I want I want people to get to that bit because it's super important. Um you talk a bit about uh excitogens, um excitotoxins, glutamate and aspartame. So we've talked about that before actually with uh Professor Garan uh who did the book on sugar. Um but I thought that was very interesting as it as it pertains to um uh uh chronic pain. One of the things I wanted to ask about were nutraceuticals. So I I always get asked about nutraceuticals about whether, you know, I should be taking ashwagandha or turmeric or coQ10 or insert whatever's popular at this point. Do you have any things that you think warrant a bit more attention or you think are actually some things that have got relatively low risk uh profiles that that you know, you you routinely mention in clinic if if patients are willing?
Dr Deepak Ravindran: So, I I really would love for a more robust set of research to probably come out. Um I I think uh it is lacking in that form, Rupy, but I do mention exactly, I think as what you said, curcumin, coQ10, these are my standard sort of go-to suggestions of nutraceuticals. Um I don't know of any other uh ones that I do prescribe. I talk about a few other things like butter, you know, feverfew and uh some of the roots that I mentioned in the book there. Uh but I don't have a bigger opinion on other things. I try I have tried to stick uh to being within the mainstream side there on that front because I'm still learning around the nutrition part myself and I'm mindful that I don't want to say something that pits the patient against another healthcare professional or a dietitian who might say that's not right. And you know, uh what I'm very conscious of trying to do is trying to ensure that we all sing to the same hymn sheet. So I try to make sure that I speak to my uh physio colleague, my nutrition colleague, and then uh other colleagues in primary care to ensure that at least the patient starts to hear a similar theme with no major divisions of opinion because if we want them to change, you know, if behaviour change has to happen there and we want them to look at a new model and a reframe, then I think making sure that they hear the same message about six or seven times from different people is very important because that's when I think, you know, there's a possibility that they will consider that change. So I'm mindful that I don't want to create too many things. So yes, I've I've kind of, I think long rambling ways, I don't go any deeper into nutraceuticals than probably what you've outlined out there.
Dr Rupy: Yeah, yeah, that's a really good and and you know, touching on what we've already talked about with neurons that fire together, wire together. I think that's why so many people are confused about nutrition because if you open up a newspaper or you look online and all you'll see is fights and that's why people are very confused about what they should be eating. Whereas in reality, it should be very simple. The science is complex, the solutions are simple, implementation and execution is hard. And so, yeah, trying to uh sing from the same hymn sheet, I I completely agree with.
Dr Deepak Ravindran: And I think that implementation execution is what I think the next phase of, you know, our healthcare professionals, my desire would be that, I think about uh a year ago or maybe just before the pandemic, Prue Leith had actually come to the Royal Berkshire Hospital. And actually my desire would be that over the next one or two years if it's possible to have, you know, the staff kitchen or maybe the pain clinic would have a small kind of a culinary kitchen or something wherein we can just teach patients some simple, healthy things that they can cook or do and show them that it can be easily done. The implementation and the execution part that, okay, you know what, I may be saying an anti-inflammatory diet, but it still feels vague to you or you may think that getting a a two-pound microwaveable meal is a much easier job. But if we can show them that it's easy to get these food stuffs and actually do it and it's still filling and nourishing, then that will make them change or at least consider that it's possible. I think that would be the ideal way to actually help with implementation for a lot of our more vulnerable patients where nutritional targets could very well be an option.
Dr Rupy: Yeah, absolutely. So Prue um is a wonderful person. She is someone who supported me with a nonprofit and and we've done a show together and everything. Um she is also part of the NHS food review. Um and one of the uh one of the suggestions that's actually in in place right now is to have an NHS chef of the year award. And that is to highlight excellence within the public catering field, particularly within those who work in hospital environments. So what they're trying to do is A, transform the branding of NHS food from one that is seen as, you know, nutritionally poor, tasteless, uh not well prepared to one that's actually quite aspirational and people actually see as another means to health and well-being and something that they hopefully extend uh post hospital stay or post whatever institution they might be in. Um so I will keep you up to date with that because I I I recently presented at the NHS um chef of the year award. Uh I can't make the finals, um but uh they are so uh enthusiastic and motivated for it. The chefs in who work in the NHS systems, uh that we've got some absolute gems and we need to shine a light on those because they could help, they could really help in like spreading your message as well.
Dr Deepak Ravindran: It is. I think uh one problem small part is obesity itself is a pro-inflammatory situation. You know, just the fact that you've got the fat on the inside, even though you may look thin on the outside, or just being obese is going to release inflammatory chemicals which are going to accelerate your pain sensation. So that is another reason where, you know, how we eat and what we eat and how much we eat and when we eat is all vital to managing pain better.
Dr Rupy: Yeah, absolutely. And you know, it it springs me to a point that I don't think I make um enough on the podcast. It's why I love talking to NHS physicians with experience because I speak to a lot a lot of people from different backgrounds in different countries, including America. And obviously, God bless the Americans, love them. They're fantastic, but they don't have a deep appreciation for having to deal with the cost-benefit ratio and uh the universal health care system um that you've eloquently described there. You know, we we have to make pragmatic decisions about management and the uh the risk of harm as well as the risk of uh draining the system of money such that we can't spread the um the health care uh providence, you know, across the population. So I think that that's a really, really important point. Um and if there are pragmatic, effective means to treat people, be it with food, be it with psychological therapies that are cheaper, incur less uh side effects, uh or less risk of side effects, um then yeah, it's definitely something that we have to entertain uh more seriously.
Dr Deepak Ravindran: I mean, I I write in the book as well towards the end, you know, when I ask patients to make a plan of, you know, how they're going to sustainably manage their care, because the reality, like I I wrote the book keeping our NHS in mind there, but it is applicable to most health care systems across the world, is really that concept that everybody's saying, oh, we should self-care more, you know, we should teach people how to self-care. And I think that's where you're doing such a fantastic job with, you know, with your culinary medicine, with the way you're setting up uh this way of actually teaching the doctors on how to cook and show that nutrition can make an effect there, because what we've traditionally done is a model for for the lack of again, any comparison, a metaphor I talk about in the book is we've always used a a DFY model, you know, done for you. You come to hospital, you lie down quietly, we'll do the surgery, we'll give you the drug, you follow our instructions, everything. And then in a very short space of five to 10 years, we are telling them DIY model, do it yourself, you know, just look at a list, do a copy a paper, look at four exercises on a piece of paper and carry away with it. And actually, there are approaches like the pain management program, which is like a DWY, done with you. You know, you sort of you teach them how to do it, you take them through it, you start off the process and you take them there. And what we don't do as a health care system is we don't provide enough funding and recognition for the DWY, which is a very necessary bridge to get people from DFY, which is apparently becoming unsustainable for any health care, including NHS or there, to DIY, which will also become unsustainable for the patient because you're asking the patient to then cough up their hard-earned money, but you're not giving them the skills to do it or where to go and do it. And so I think that is a necessary step and I really applaud you because in terms of doing the, we need more of that kind of work wherein we empower our health care colleagues as well as our patients with almost a handheld strategy to make sure they're comfortable and then let them fly.
Dr Rupy: Yeah, you know, this is what I was referring to actually at the start of the podcast, which was perhaps the most important takeaway for me was this uh categorization and it's something I haven't been able to articulate as well as you've done with the the the three uh the the acronyms or the um the abbreviations, the done for you, done with you, do it yourself models. So I love how, you know, medicine currently and certainly uh my experience of it over the last 20 years has been you have a patient in front of you and they are passive in acceptance of drugs and surgeries. You have some element of partnership where you have a physio or you have a health coach or you have someone supporting you through your journey. But the patient-led side of things is something that we've gradually eroded, I think, over the last 50, 60 years as the importance of uh pills over plates or pills over, you know, insert intervention that you do at home, um has taken precedence. So I think restructuring that such that there's more symmetry across them is the overarching goal, I think, of health care if it's going to be sustainable in the future. So that I just thought that was just such a wonderful element. It's right at the end of the book and I want I want people to get to that bit because it's super important. Um I don't think I've spoken about this on the podcast, but I I myself am I'm not unique, obviously, there's there's millions of people across the UK alone that have chronic pain, but I've had um chronic low back pain since I was 15 or 16. I used to play a lot of tennis and my serve was obviously off and I would practice really hard and I that that caused uh right-sided back pain. I've had it my whole life. And I was reading the book and as I was reading it, I was like, I've been incorporating these techniques almost naturally along the way, but it's lovely to have just a manual almost of all the selection of different things that I could do or could have done to improve pain. And looking at flare-ups, having a flare-up plan, uh knowing your triggers, as well as all the other things like exercise, movement, all the things that I have to do every single day to manage my pain, um it it was it just resonated with me so much from that perspective as well as, you know, from a clinician's point of view. And I I just think it's uh it's just very, very well done. And you know, my mom's going to listen to this podcast and she's just going to say to me, well, this is all you guys have been talking about is just Ayurveda. It's just it's just Ayurveda. Why don't you just call it Ayurveda? Why don't you
Dr Deepak Ravindran: One of my friends actually had written a book on Ayurveda. She's a practitioner in in the US and her she's sort of finished her medicine and kind of moved from mainstream medicine to the Ayurvedic discipline. And and she'd read the book and actually said, you know, what you're saying is actually what I'm actually teaching in my Ayurveda college here in the US as well. I said, well, there are some aspects of Eastern slash spirituality and that kind of practices which now the West is willing to accept as mainstream because we've now got the MRI and the scientific evidence to actually accept it. It's it's how probably people have accepted it there. I think it's the culture, isn't it? It's it's how the American and UK-based cultures often look at good evidence and want to be on sound scientific principles to accept it. And now we've got the evidence that a lot of what our mums used to say and my grandma used to say has now got solid scientific foundations. You know, the admirable thing is they twigged it 100 to 200 to 400 years ago without the MRIs.
Dr Rupy: Absolutely, yeah. And I have to ask this as we uh as we finish up here, um because I want to be mindful of your time. We've been talking for nearly two hours. Um what what kind of uh spiritual or um psychological practices that you do you entertain every day? I mean, my myself, I I meditate. It's now been part of my regime for for many years and I have a gratitude practice as well. Um but but are there are there any that you found personal benefit from?
Dr Deepak Ravindran: So, I I do a gratitude practice as well in the morning there. Uh for me, mindfulness and in that I try to bring in mindfulness with running or walking. So I try to ensure that every day I try to do some visualization techniques, some gratitude, a little bit of journaling if I can, at least on twice a week in there. I've got one of these nice journals to sort of look at it there. But my main thing is mindful-based walking or running. That way I I include my physical activity, but I just allow for the drama of the day to actually get washed away to a certain extent with that way. That's been my in there. And intermittent fasting for me, I found that really useful uh as a way of actually helping me get into there as well.
Dr Rupy: This has been uh amazing. I I've absolutely loved talking to you. I would love to talk to you again at some point in the future. I uh I want to I want everyone who works in the NHS to read this book. I think it's fantastic and it's regardless of whether you, you know, you work in pain or not, I think it's a blueprint for how we should be uh thinking about health care at a wider at a wider level. So, I congratulate you on on writing such an incredible book and I I can't wait to to see how it grows.
Dr Deepak Ravindran: Thank you, Rupy. That's very very wonderful feeling to actually hear that from you. So thank you so much for that.
Dr Rupy: Hopefully, I can say to you, I told you so. Dr Deepak Ravindran, he is an incredible human being, an incredible consultant, one of those people that I wish everyone had access to. And you can, you just need to pick up his book, The Pain-Free Mindset. It is a fantastic book. If you've liked listening to Dr Deepak and what he has to say, he goes into a lot more detail in the book. There's so much information, there's no way we can cover everything. So, so do check it out. Um and uh I will be putting links as well to everything that we talked about on the show notes and the doctorskitchen.com, plus the newsletter where we give something to eat, a recipe for the weekend or the weekday, plus things that will uplift your mind and mood to listen to, to watch or to read. Check it out at the doctorskitchen.com and I will see you here next time.
