Dr Megan Rossi: And in the book I do give a little bit of a probiotic prescription kind of highlighting where the evidence has been. You would then go, okay, so there has been some evidence, what sorts of probiotics have shown a benefit? So you identify the type of probiotic, which we call the strain. And then the other thing you need to think about, well, what dose did they give to have that benefit? Then, what duration? How long do I need to take this before I should start to see a benefit? And also how you should take it. Should you take it on an empty stomach or with food, etc. So what I recommend, and I've given those prescriptions in the book, is really just reflecting the clinical trials. So you're kind of just repeating them because they're the ones that have shown the evidence. So why wouldn't you, instead of just taking a stab in the dark?
Dr Rupy: Welcome to the Doctor's Kitchen podcast with me, Dr Rupy, where we discuss the most important topics and concepts in the medicinal qualities of food and lifestyle. And my guest today is Dr Megan Rossi. Yes, she's coming back for a second instalment. She's been on before talking about all things related to gut and fibre, so I highly recommend you listen to that episode from the very first season of the podcast over two years ago now. But for now, if you don't know, Dr Megan Rossi is the Gut Health Doctor, a registered dietitian and nutritionist with an award-winning PhD in gut health, and she's also a leading research fellow at King's College London. And she has just published her first book, Eat Yourself Healthy. On today's pod, we talk about so many different things, including the difference between the microbiota and the metabolome, food additives, as well as step-by-step guides as to how she deals with people with bloating and all the other common gut-related issues in clinic. It's great to have you in the kitchen.
Dr Megan Rossi: It's a pleasure to be back. Although not in this kitchen, new kitchen.
Dr Rupy: I know, new kitchen. New kitchen, everything. This is your second time on the pod. Congrats.
Dr Megan Rossi: You can call me like an expert.
Dr Rupy: You're one of only, I think, three people that have made a second appearance on the pod.
Dr Megan Rossi: That's a title I want to keep. Let's keep that number down, please.
Dr Rupy: Let's keep that number down. Exactly. Yeah, totally. So, today I'm going to be making a modified recipe from your fantastic new book. I absolutely love it. The Gut Health Doctor, Eat Yourself Healthy. I think it's really, really good. We're going to be doing a chia jam. And you've got some lovely goodies as well, right?
Dr Megan Rossi: Yeah, yeah, yeah. Some show and tell for you guys.
Dr Rupy: I'm going to be making it on, I'm going to be putting it on some toasted bread as well. So this is a bread recipe that's not mine, it's from My New Roots. I don't know if you've heard of it. The life-changing bread. Yeah, so it's just combined oats, some hazelnuts, flaxseed, psyllium husk, all gut-loving ingredients.
Dr Megan Rossi: Diversity. I'm sure we'll talk about it, but that is key. Oh my god, I can't wait to get into it. Yum.
Dr Rupy: So I'm just going to slice this and put some on. I don't have a toaster in this place. Can you believe that?
Dr Megan Rossi: I know. You know what, I think toasters are overrated.
Dr Rupy: And this is, this is quite small as well, so it probably, probably would fall in the cracks of the toaster as well. So I didn't finish the recipe. So this is, I'll link to it in the show notes, but basically, it's all those ingredients mixed together with a bit of coconut oil, some chia, and then you let it set and then you basically bake it for around 45 minutes, let it cool down and then you have this like amazing loaf. And I mean, I would go through this entire loaf in one sitting to be honest. It's really, really good.
Dr Megan Rossi: It's really tasty, right? Well, you've talked it up, so let's hope it's not a disappointment.
Dr Rupy: I'm going to burn it. So just keep an eye on it while I do my job.
Dr Megan Rossi: I have to be useful.
Dr Rupy: Okay, so your chia recipe, you stew some apple. I know I've seen you do one on Instagram where you stew apples.
Dr Megan Rossi: Yeah, yeah, but this one is just a mix of berries. I often use blueberries, particularly the small ones, because the small ones actually contain so much more antioxidants. Again, a lot of them are really good for the gut bacteria. And then add in a little bit of date just to increase the sweetness. Just simmer it on the pan and then let it kind of form this gel consistency, but then you add the chia seeds.
Dr Rupy: Cool.
Dr Megan Rossi: Which really do help.
Dr Rupy: I'm doing it slightly differently.
Dr Megan Rossi: I'm all about adapting recipes.
Dr Rupy: Yeah, yeah. So frozen berries that I've just got from your standard supermarket, a lot cheaper, maintains a lot of the nutritional content. Mixed seeds, some chai mix. So this has got cinnamon, nutmeg, a little bit of ginger powder in as well. It's really, really good. You can buy them in most supermarkets now. Maple syrup for sweetness instead of the dates that you used. And then I'm going to add lemon.
Dr Megan Rossi: Although I would just say we should probably use the whole dates for the whole fibre in, but you know what, I'm not going to judge you, Rupy. Let's go with your plan.
Dr Rupy: I couldn't get dates, okay? The rest is amazing. I love all these other adaptations.
Dr Megan Rossi: Good, good.
Dr Rupy: Orange juice, lemon, a little bit of water, chia obviously, and just let it set and then that's all I'm doing. And then I've got one pre-made in the fridge from yesterday. So that's just another way of making jam, but I think your recipe is great, particularly as you can use sort of like stewed apples and stewed harder fruits and pears and that kind of thing.
Dr Megan Rossi: And the thing is you don't need a whole lot of ingredients. It should be something quick because unlike you, you're an amazing chef. I'm a novice cook, so I'm just all about the quick convenient.
Dr Rupy: Okay, well, whilst I prep this, tell us what's been going on since the last. It's been two years since you've been on my pod.
Dr Megan Rossi: It has, which has, it's absolutely flown. I can't remember when we first got chatting. It was when I just really started in the world of public engagement, social media. And yes, from that, so many things have happened. So obviously the book took up a lot of my life.
Dr Rupy: It has been for a while as well, hey?
Dr Megan Rossi: Yeah, look, it's, it's been a slow burner because I was continuing full-time research. And I also am a little bit OCD, so I had about 20 of my clinical colleagues like review every chapter with a fine-tooth comb.
Dr Rupy: Yeah, I noticed like Whelan and Yao, I think, and there's a couple of other people that you mentioned in the book. I was like, oh wow, a lot of people have read this.
Dr Megan Rossi: Yeah, just because I, I don't know, like a lot of the things in there is like a protocol which hasn't been published before and it's all about the evidence base. So I wanted to make sure it was peer-reviewed. And yeah, I also started the Gut Health Clinic. So a team of gut health researchers who also work in clinical practice on Harley Street. So we deal with people with gut issues, inflammatory bowel disease, irritable bowel syndrome, but also people who just want to, you know, make the most out of their gut. And also, because there's more and more research coming out in the space of the gut-brain axis and how we can actually help our mental health by looking after our gut health, I've actually started to get a lot more patients who have mental health issues.
Dr Rupy: Yeah, so it's, yeah, it's really exciting.
Dr Megan Rossi: So I noticed one thing I love about the book is that you've got a lot of patient anecdotes from clinic in there as well. And one of them was...
Dr Rupy: Obviously all de-identified.
Dr Megan Rossi: All de-identified. Yeah, of course, of course. I got this image of like Dan from the book like, oh my god, my history is in here. Why did you do this? But no, I think that adds another dimension to this book, which is distinct from anything else that's out there because it's, it's, you know, combining the evidence base with the anecdotes from clinic as well as like some usable tips for the user, right?
Dr Rupy: Yeah, because you know, I've come to appreciate that science for many people isn't overly exciting and enticing. So I wanted people to be able to relate to the evidence and how I did that, hopefully successfully, was yeah, sharing some patient stories to see how they were able to translate and actually, you know, really get the most out of their gut, which is like this, you know, inner organ or inner universe of potential, I like to call it, Rupy, a little bit lame, but that's what I truly believe.
Dr Megan Rossi: It's not lame at all. No, that's brilliant.
Dr Rupy: And so, so you mentioned mental health. So we actually had Professor Felice Jacka, the lead author of the SMILES trial that you refer to quite a bit.
Dr Megan Rossi: My favourite study.
Dr Rupy: Yeah, yeah. And she's great and she's Aussie as well.
Dr Megan Rossi: Yeah, yeah. All the good things come out of Australia. Like your girlfriend.
Dr Rupy: So, are you noticing that a lot more people are coming to you with mental with mental health issues because they know that there's a gut connection there as well?
Dr Megan Rossi: Yeah, absolutely. And I think on that, that note though, it's really important to highlight that if you do have mental health issues, it's not just cure it with diet all the time. You know, some people do certainly have, you know, hormone irregularities and they certainly, for some time in their life, need to go on some medications. So I think that's really, really important for people to understand. But yeah, the, you know, the research is really quite strong to show that diet as an adjunct therapy, so an additional therapy for those who have quite severe depression. And I'm a big believer, you know, in earlier stage mental health issues, we could actually probably prevent people needing medications if they start to, you know, look after their gut microbes via things like their diet, lifestyle, sleep, stress, etc.
Dr Rupy: Absolutely. And I noticed like one of the anecdotes, one of the patient stories there was one a patient who had already been started on antidepressants by their general practitioner. And then, like you said, as an adjunct, when changing some of the dietary things and some of the lifestyle factors as well, you were able to potentially get them to come on to a lower dose of antidepressants.
Dr Megan Rossi: At least, right? Yeah, absolutely. And again, always done with their healthcare professional, like their GP, or their psychologist, the psychiatrist, because it is, you know, risky business when it comes to mental health and I don't want people to go, I'm just going to drop all medication, go completely natural because they can really have a low point. So it's all about safety, but yeah, power of food and nutrition is huge.
Dr Rupy: Yeah. Obviously, you know that, which is why you've converted from the medical world.
Dr Megan Rossi: But there's a lot more of us out there. Hey, all right, this is going into the fridge. So I've just put everything in here. So frozen berries, the mixed nuts and everything else. And this is just going to defrost essentially.
Dr Rupy: Yeah, give it a good smell.
Dr Megan Rossi: Oh, it's so good.
Dr Rupy: Is there the chai mix in there as well?
Dr Megan Rossi: I really, I think I'm going to love the lemon.
Dr Rupy: Yeah, the lemon and the orange. Yeah, yeah, absolutely. Adds a little bit of sweetness as well. And you might have shown me up with my recipe.
Dr Megan Rossi: No, no, of course not. This is just adding a few extra bits. Because I think like the simplest way is the best way to start and then you can be experimental with it, right?
Dr Rupy: Yeah, totally. So yeah, this is what it looks like afterwards. So you can see the chia has sort of like become a lot gelatinous and it's soaked up a lot of those juices from the lemons and the orange. And give that smell as well. It's got like the smell.
Dr Megan Rossi: Yeah, that is, that's a winner. Oh my goodness. Yum.
Dr Rupy: So tell us about your goodies that you've brought in. So you've got the live yoghurt. Again, another recipe from your book.
Dr Megan Rossi: Yeah, so in the book, I just show how people can actually make their own live yoghurt literally by getting a scoop of some live yoghurt they've bought from their local supermarket, putting in some more milk, and then putting it in the oven just for a short amount of time at a really low temperature and they kind of grow their own microbes. And what the microbes do, so the bacteria can actually eat some of the lactose, the milk sugar, and then produce some of these organic acids which are thought to be really beneficial for us and it gets quite creamy, a little bit tart, which is why I always combine it with the chia jam to add it in. And it's a super easy thing to make. But what I'm really passionate about is actually kefir.
Dr Rupy: Yeah.
Dr Megan Rossi: As you know, you've probably seen. Now, I think, you know, a lot of people kind of go, oh, is this just another fad? But it's true, the scientific evidence isn't overly strong for fermented foods. In fact, our research group just published a paper and showed that there is a little bit of evidence. Kefir probably has the most evidence out of all fermented foods.
Dr Rupy: Oh, really? Okay.
Dr Megan Rossi: Yeah, but it's, it's not that strong. But anecdotally, you know, ancestors have been associating it with benefits for, you know, thousands of years. And, you know, it's super tasty, which is why I guess I actually got into it because of the taste element. And then I thought, oh, you know, I might give myself a bit of a gut health experiment at home. So in here, I'm not sure if you're able to see it, but you can see like these little cauliflower things.
Dr Rupy: Oh, wow. Yeah, yeah.
Dr Megan Rossi: Yeah. So, yeah, so you can't actually, that's not actually the microbes. So the microbes are invisible to the human eye, but like a spider builds a web, these microbes build these little cauliflower things to live in. So in here, there's millions of these microbes. Bacteria, including yeast, and many yeast are actually beneficial, although people kind of freak out about it. But yeah, some yeast are super beneficial. We all have yeast in our gut which look after us. So all you do is pop this in some milk, leave it on the bench, so out of the fridge for about eight hours, depending on the temperature, and then literally in the morning, you have kefir. You just strain out the grains, and then the bottom of it, you've got this fermented milk, and then you put the grains in some more milk and literally as simple as that.
Dr Rupy: I've noticed on your Instagram, you put the kefir grains and the actual pots near your heater. Is that right?
Dr Megan Rossi: Yeah, yeah, yeah. Because they, they prefer to live in around, or they ferment best around 25 degrees. So obviously London's not always 25 degrees. Australia maybe. So yeah, I put them near that so it warms up and it helps them ferment that a little bit faster. If it's too cool, they actually go to sleep, which is why if you, you know, going on holidays, you always put your grains in the fridge to kind of slow them down.
Dr Rupy: And you've got a plant-based version as well.
Dr Megan Rossi: Yes, and there's also water kefir. So again, you can see these little clear grains. So these look more translucent. I should have probably done that with the milk.
Dr Rupy: So how do these, how do these actually stay alive then if they, what's the sort of source of energy?
Dr Megan Rossi: Yeah, so for the kefir, it's the lactose, the milk sugar, which is why if you put these grains in a plant-based milk without lactose, they won't survive, they'll die. Whereas these guys here survive on things like glucose and sucrose, so like normal table sugar. So to actually make this, you just have some sweetened water, and you put a little bit of lemon in to get a little bit of an acidic environment. And then every couple of batches, you'll add like a fig to give some more nutrients to these microbes. But they mainly ferment and eat the sugars.
Dr Rupy: All right, okay, fine.
Dr Megan Rossi: And then again, they produce the different range of organic acids and some of the waste product is the gas, which is why it gets really quite fizzy.
Dr Rupy: Okay.
Dr Megan Rossi: In fact, I've had a massive explosion in my house. So I think the water kefir is a little bit more of a risky one to make if you're not as experienced, but the dairy kefir, it's super easy and it's less hazardous.
Dr Rupy: Brilliant. Okay. I'm going to get you to help me with making these for the team. So we have that bread that I've just dry toasted on a pan.
Dr Megan Rossi: Oh my gosh, it tastes like hazelnuts. Amazing.
Dr Rupy: I know, yeah, they're delicious, right? And the recipe for this is going to be on the show notes as well. So I can't claim ownership of this recipe. It's definitely nothing that I could have come up with myself. Do you want to dollop some of this on top as well? Let me get you a spoon. This is super exciting. This is the first time I've actually got a guest to bring in stuff that we're using.
Dr Megan Rossi: Well, I can't help myself. Like I said before, my mum's a science teacher, so I'm all about the show and tell.
Dr Rupy: Yeah, yeah.
Dr Megan Rossi: Now, to get this a little bit extra creamier, I added some more milk powder before I put it in the oven, so it's nice and thick.
Dr Rupy: And for those of you listening to the podcast, you can watch this on YouTube as well.
Dr Megan Rossi: I know, yeah. I always watch cooking shows though and go, God, can you send us like through the TV? And now I'm finally on one. It's like the best thing ever.
Dr Rupy: This is going to be the first of many, trust me, I'm sure. Okay, so I'm just going to dollop this on top, right? Is this how you would have it?
Dr Megan Rossi: Yeah, I usually would have it in like a little pot with the yoghurt and then add a teaspoon. It's like a snack on the run. But yeah, love a bit of mixed seeds and hazelnuts and oats in your recipe, so.
Dr Rupy: And I'm sure you'd use a suitably hipster-like pot as well.
Dr Megan Rossi: Non-plastic.
Dr Rupy: Absolutely, yeah.
Dr Megan Rossi: Show up on the tube to everyone.
Dr Rupy: Do you want to grab that? Do you want some knife and fork or you just going to...
Dr Megan Rossi: I'm Australian.
Dr Rupy: Okay, go. Just in case anyone hadn't realised. Are you calling me bogan?
Dr Megan Rossi: I'm going to try this as well, actually. So I'm super looking forward to this.
Dr Rupy: Wow. That sourness of the yoghurt is delicious.
Dr Megan Rossi: Yeah. Matched with that little bit of sweetness from the berries.
Dr Rupy: Yeah, yeah. That's great. And the herbs and spices are awesome.
Dr Megan Rossi: And the loaf, it is really moist. Surprisingly, it looks kind of dry, but...
Dr Rupy: I know, yeah. It's got some oils in it. When you dry toast it, it kind of comes out.
Dr Megan Rossi: Okay.
Dr Rupy: How was your, how was the bread?
Dr Megan Rossi: Yeah, it was super tasty. I really love the extra spices you've added to.
Dr Rupy: Oh, nice. Good, good. For book two.
Dr Megan Rossi: Yeah. I'm going to write that one down.
Dr Rupy: So the process of you writing this book has been very long. I remember the last time we spoke, you were about to start a trial on food additives.
Dr Megan Rossi: Yeah.
Dr Rupy: You got a grant for that, right?
Dr Megan Rossi: Yeah, yeah, yeah, absolutely. So looking at different types of food additives, particularly in those who are genetically susceptible to getting things like inflammatory bowel disease. We think they might not be that great. And if you look at the food supply, they're found in like 30% of the foods we eat.
Dr Rupy: Yeah. So it's a super important trial to do.
Dr Megan Rossi: Really, really important. And it's actually the first, I guess, large clinical trial that's ever been funded looking at diet in inflammatory bowel disease. Historically, it was kind of thought, you know, inflammatory bowel disease, IBD, is really just drugs, you know, this is the way we have to work it. But a lot of patients now have been advocating that they want to know more about the diet because a lot of them think that there is some link there. So yeah, a charity from the US actually funded the grant. It was like 1.2 million. So it's massive clinical trial for for diet anyway.
Dr Rupy: Yeah, and very much needed as well because I think like you said, particularly from your experience in clinic now, I guess you're getting a lot of patients coming in who feel that they have reactions to certain foods that they're eating. And I love the way that you've tackled this in the book because you use some incredible diagrams and lots of like, you know, the chapters themselves are just so informative. Tell me about that process because it must have taken ages and you already told me before that you overwrote by like a huge margin. So...
Dr Megan Rossi: 300 pages. So I guess a lot of the the flow diagrams that kind of personalize the nutrition is really just was a brain dump from what I would do in clinic because I wanted people to get that personalized kind of feel and because that's the only way essentially you really get the best, you know, recommendations and the best strategies is when it's personalized to the individual. But of course, I can't see everyone in clinic. I don't have enough time. And I don't want people to have to pay for, you know, a private dietitian, which is certainly not attainable for everyone. You know, growing up, I certainly couldn't have afforded it. So I wanted the book to have that personal feel. So yeah, a lot of the ideas were just things that I would go through in my own head when I'm seeing a patient right there in front of me. I've just written it down in a flow diagram.
Dr Rupy: Yeah, yeah. And you said that you got a lot of your peers to sort of review the diagrams and review the information. So it was peer-reviewed.
Dr Megan Rossi: Yeah, absolutely. I was a little bit anal about that because, you know, a lot of the pathways were my own clinical insight. It wasn't necessarily a published, you know, guideline. So yeah, getting them to review, I think it was like over 20 with a fine tooth comb, a lot of challenging, which I loved, and then tweaking things accordingly. So yeah, no, I am really proud of what's come of it.
Dr Rupy: Yeah, and you should be because I think it's going to be super helpful for people. One of the things I love actually was on page 55 from memory was the probiotics, how to choose your probiotics. A little, little sort of flow diagram. I get asked about that so much in clinic, in A&E as well. Can you summarize that for us? Like that that little section?
Dr Megan Rossi: So I think it's really important to firstly understand what probiotics are. So probiotics are certain types of live microbes, mainly bacteria, but not all, there are some yeast probiotics, which have shown to have a benefit. Now, the thing with probiotics is that there are thousands out there. And each different probiotic actually does different things. So we need to kind of think of it like, you know, vitamins. If you've got iron deficiency, you're not going to go and take a vitamin D supplement and think, you know, you're going to cure your iron deficiency. The same with probiotics. Each one is actually different, which is why I've written the the process. And if you do, you know, want to improve some sort of symptom, first you need to see, is there any evidence? Has there been any trials showing there's a benefit? So things like mental health, you would then, firstly, yeah, determine whether there has been any evidence. And in the book, I do give a little bit of a probiotic prescription kind of highlighting where the evidence has been. You would then go, okay, so there has been some evidence, what sorts of probiotics have shown a benefit? So you identify the type of probiotic, which we call the strain. And then the other thing you need to think about, well, what dose did they give to have that benefit? Then, what duration? How long do I need to take this before I should start to see a benefit? And also how you should take it. Should you take it on an empty stomach or with food, etc. So what I recommend, and I've given those prescriptions in the book, is really just reflecting the clinical trials. So you're kind of just repeating them because they're the ones that have shown the evidence. So why wouldn't you, instead of just taking a stab in the dark?
Dr Rupy: Exactly, yeah. Which is what a lot of people are doing these days. They're just like, oh, I bought probiotics. What probiotic did you buy? I don't know. It's the same thing. I it's quite frustrating actually. I'm sorry to get my high horse about this, but when I ask patients about what antibiotic they had, they literally can't remember. In a lot of cases, they can't remember. And that's just, it doesn't give me any information whatsoever. So it's the same thing with probiotics.
Dr Megan Rossi: It really is. And it, I kind of feel sorry for probiotics because it gives them a bad name in a way because people are like, oh, it didn't do anything for me. And I'm like, well, you probably just didn't take the right one. Now, it's true that if you are generally healthy, then you don't actually need to be popping a capsule every day. You know, I'd recommend just getting some fermented food in your diet, things like the kefir, the kombucha, kimchi, etc. Not a lot of evidence for it, but I think it's tasty, include it, why not? It could have a benefit. Whereas there are some indications where there is good evidence. So the one with the strongest evidence is if you are taking an antibiotic, then taking a specific type of probiotic throughout the duration of your antibiotics and for a week after has a really good evidence behind reducing a risk of antibiotic associated diarrhea, which is something that affects around 30% of people who take antibiotics. So, not to get too technical for the listeners, but it the probiotic would be Saccharomyces boulardii, and you would take that twice a day at the dose of 5 billion. And when we talk about probiotics, we call them CFU. It's kind of like the unit of measure, colony forming units. Like we talk about protein, we talk about grams, bacteria and microbes, we talk about CFU. So it's 5 billion twice a day. So it's very prescriptive, like you would with medication that you prescribe people. And we need to be doing that to get the most out of probiotics.
Dr Rupy: And do you think like this is a huge computational issue, right, for a lot of researchers because depending on the research cohort that they were using, they're going to have different microbiotas, right? And then depending on what strain is being introduced into that microbiota is going to have a differing effect. So how do we even start with trying to relate that piece of research to the person in front of you where you basically have no information about any of those different things?
Dr Megan Rossi: Yeah. That's such a good question. I think it's really important and why in the book again, I've only put the evidence for the ones where there's been a meta-analysis. So a meta-analysis is really where they pull all the individual clinical trials which look at all different populations and they pull it together and they look at the overall benefit. Now, if the meta-analysis from that has shown a benefit, then I say, well, there's, you know, a good chance. Now, it's certainly not going to say 100% this probiotic will work for you, but there is more of a chance. Now, if there's only just a single study, it is a bit risky because like you've said, how do you know it's relatable to, you know, different age groups, different environments, etc. In fact, some of our research which we published, I think the end of 2017 maybe, or maybe it was 2018, it actually looked at whether we could predict whether someone would respond to a probiotic based on a stool sample. So we took a stool sample of people at baseline before they took the probiotic and then using the baseline sample, we were able to determine whether someone would respond. And that was in a population with irritable bowel syndrome. So there really is a lot to come in the in terms of personalizing nutrition and therapies based on the stool, our gut microbiota, which is those trillions of bacteria. But big butt, it certainly isn't ready for translation yet.
Dr Rupy: If you were to look into your crystal ball, right, in the future, say 15 years down the line, do you envisage a time where we're going to be doing a stool sample in addition to all the other tests that we do prior to prescribing antibiotics, where we can predict A, whether you're going to respond to this antibiotic, and B, whether this antibiotic is going to be detrimental to you and what probiotic you should therefore be taking to mitigate that risk?
Dr Megan Rossi: 100%. Yeah. I would even say maybe in the next 10 years. Yeah, there's many researchers looking at this. Now, there are companies who've already are claiming that they can do that. And unfortunately, they can't. Those, you know, algorithms aren't validated just yet. But I'm yeah, a big believer that definitely in the next 10 years, there will be that sort of, yeah, personalized approach.
Dr Rupy: So for, there's a lot of doctors that listen to the podcast, right? And they often ask me what antibiotic, what probiotics I suggest for people with UTIs or with traveler's diarrhea or pneumonia. Can we put people in buckets according to what condition or symptoms they're suffering and then prescribe probiotics on the basis of that? Or does it really depend on that individual? I mean, I'm sure it's the latter, but yeah.
Dr Megan Rossi: Yeah, yeah, yeah. So there obviously is that dependence on the personalization, but when we look at those meta-analysis, if it's been done in a wide population, then we can hedge our bets that, you know, if they want to try it, it's probably worth taking this specific strain at this specific dose to have that benefit. But yeah, of course, you can't promise that it's going to completely revolutionize, you know, everyone's conditions by taking, you know, that probiotic.
Dr Rupy: And on your website, do you have a probiotics sort of guide? I think I remember from the the gut health. Is it the gut health, sorry, the gut health clinic or the gut health doctor.com?
Dr Megan Rossi: So it is the gut health doctor.com, but if you put the gut health clinic.com, it also goes to the same website. It's very tricky, very tricky. Do not worry if you get it wrong. You can't miss it. But yeah, so from the book, because again, they made me cut out so many pages. I actually had that probiotic prescription in the book and they're like, there's no space along with quite a few other assessments. So I've now put it on the website. So people can access that. And like I said, they're the main areas where there is good clinical evidence, so I would recommend taking the probiotic and again, I've listed out the strains, the doses, etc. But I think, you know, in the next five years, I think I've only listed about seven conditions, those number of conditions, hopefully, will be, you know, much more than seven.
Dr Rupy: Well, I think that's a good thing that they made you cut it out, right? Because then that list can now be dynamic and you can add things to it, take things away, etc. So...
Dr Megan Rossi: Yeah. There was method to their madness.
Dr Rupy: Yeah, yeah, a silver lining, absolutely. So, you know, one of the things that you, one of the ways in which you describe the book, which I thought was really telling, was that this was a safe space in which to discuss gut health because you're aware of sort of the fads and the tests that people are promoting that aren't evidence-based. How did you even start that sort of that journey, I guess? Because there's a lot of misinformation out there. So you kind of need to be aware of it, but then also, you know, take people on this journey.
Dr Megan Rossi: Yeah, absolutely. And I guess, you know, how I even got into public engagement is really just through frustration. So after I finished my PhD, I moved over to the UK, started working at King's, where they're, you know, doing heaps of innovative gut health research. And I was like, this is amazing. I loved it. But about a year into my post there, I was like, you know what? It's just, it's just wrong and it's just frustrating. You know, there is so much amazing work that not just my group was doing, you know, all around the world were doing, but it's those fad and potentially dangerous messages that were being, you know, pretty much force-fed to the public. And in my clinic, I was seeing, you know, extremes. People had been taking these tests, losing like 20 kilos, really malnourished, super scared to eat anything because they've been told they've got these intolerances. You know, other people were having, you know, huge amounts of these supplements thinking they were going to be good for them and actually kind of started to provoke gut symptoms. So I guess, you know, this organ that I thought had so much power and potential was actually starting to, you know, do some harm to people and, you know, people weren't really appreciating how beneficial looking after their gut was. So that's when I, you know, got into social media. I was like, what else can people do? How else can I have a voice? And then just, you know, through word of mouth, people have really supported me. You've, you know, supported me greatly. And a heap of the different influencers. And then from that, I think I've just, you know, at the start, I was terrible with it, you know, trying to do that communication, but I've really started to, I guess, appreciate where people were coming from and that they were really, really struggling and how to kind of in a non-intimidating way share the science because science can be a little bit like, oh, that's like really boring and, you know, I don't think that will relate to me and, you know, if there's a blogger who talks about this new supplement they've been taking in a really engaging way, then that's a lot more convincing than me saying there's been a systematic review, you take this. So I think it's just about kind of bridging that gap and, you know, over time, I hope that I've learned to, you know, engage both with the fatty world a little bit because you have to understand what's going on, but also bringing that research in a more lay level.
Dr Rupy: I think you've, you've definitely bridged that really well and I've noticed that throughout your career actually that you're very engaging at, you know, showing different messages that is has an evidence base behind it. And one of the things I think is quite telling is that people are more inclined to do something in a quick fix way, whereas there's a large proportion of your book that is dedicated to things like food intolerances, which I think we should talk about because it was one of my favourite sections of the book because you go into enough detail, I should say, not loads of detail, but enough detail to give people the information that they need to know as to whether this is an intolerance or not. And actually even like taking one step back, defining the difference between intolerance and allergy.
Dr Megan Rossi: Yeah. And I think that's just so important. You know, the stats suggest that around 20% of people are actually excluding things in their diet because they think they've got these food intolerances. And when I actually go through this in clinic, most people actually don't. They might have, you know, a low level of irritable bowel syndrome, which we would manage in a different way, actually not having a super restrictive diet. So, you know, it was really important for me to include a section on how to safely diagnose a food intolerance at home because those food intolerances, you know, online that promise the world are actually invalid. They'll come back and they'll just tell you all the foods that you've recently eaten. So it's very dodgy that can exist. So the only way, the only valid way to diagnose a food intolerance, except for milk sugar intolerance, lactose intolerance, there is a breath test for that. But the others is just through this process I call my 3R method. So it is just recording everything you're eating alongside your symptoms. And then if you identify a particular corporate, you would then restrict it for around four weeks. And then it's super, super important to reintroduce to make sure that it's not just a coincidence that when you cut it out, actually it was having that benefit. So again, hopefully the flow diagrams really do help. And one of the...
Dr Rupy: They really do help. Yeah, I'm looking at it. I was like, oh my god, this is so, I'm thinking of different ways in which to explain it to people as well, using these diagrams.
Dr Megan Rossi: And I think one of the reasons I added gluten in there is again, that's one of the things people cut out. And there's some really good evidence out there to show that people who cut gluten out of their diet and they don't need to, so if they don't have non-celiac gluten sensitivity and they don't have celiac disease, if they're cutting it out, actually, they have a more or a less diverse gut microbiota, which is associated with things like increased risk of heart disease, diabetes, poor weight management, etc. So actually, you know, I'm not saying that gluten is amazing, I'm just saying that whole grains that contain some gluten, things like, you know, rye, barley, etc, actually are really beneficial. And if we're not getting that, then we're actually depriving our gut bacteria of different whole grain fibres. So yeah, I'm really hoping that people actually go, oh, I can have some of these foods. I don't need to be so restrictive.
Dr Rupy: Absolutely. And I've noticed actually a lot of patients coming in, they've restrict, restrict, restrict to the point where they actually have food in general avoidance and they get very fearful around food. And there's clearly then a nocebo effect that you actually mentioned in the book as well, right?
Dr Megan Rossi: Yeah, absolutely. It creates that vicious cycle. If you, you think, and we've, not me, but some of our colleagues have done clinical trials where they have told someone they're either going to get the gluten or a fake intervention. And they, if because they really believe that they are intolerant to gluten, and they made sure they didn't have non-celiac gluten sensitivity or the celiac disease. And what they found is that when they gave people the placebo, the fake intervention, not gluten, they actually all complained of gut symptoms because they really believed it. And it's not just, you know, all in their head, so to speak, but there is an actual physiological mechanism there and that our gut and brain are constantly communicating. So they could actually see these people physically bloating. So, you know, even if you do have the physical bloating, it doesn't necessarily mean that you have that intolerance. It is a lot with relaxing that gut brain axis, which again is that other section of the book around...
Dr Rupy: Exactly, yeah. It's a brilliant segue into the other section of the book, which is about lifestyle factors, mindfulness, and even yoga as well.
Dr Megan Rossi: Yeah.
Dr Rupy: Which I think is again, a very necessary part of the whole issue because it's not just a quick dietary fix. In a lot of cases, it's far beyond that and the brain is a very powerful thing, our emotions are a very powerful thing. So I was really pleased to see that you added that as well. Can you talk us through...
Dr Megan Rossi: Yeah, well because in clinical practice again, you know, for those listening who might have heard of this low FODMAP diet, in Australia it's become quite a fad or a trend. And what we know is actually going on a long-term low FODMAP diet is actually really not good for you. It actually changes some of your gut bacteria, which the bacteria are beneficial. So I don't want people to go on it long term. But what people find is if they just cut these FODMAPs out, yes, their IBS symptoms generally resolve. But then when they go through the reintroduction process, which is hugely important, their symptoms come back and then they get scared to reintroduce. Now, that happens because they haven't really treated the underlying cause. It's not they have an intolerance to these FODMAPs. It's actually that what we understand IBS now is a dysfunction between the gut and the brain. So everyone's gut and brain is constantly communicating. In IBS, that communication is dysfunctional. And as a result, they have a very sensitive intestine. So the FODMAPs can trigger that, but as soon as they reintroduce, often the symptoms come back if they don't deal with that dysfunctional gut brain, which is where, you know, the studies have actually highlighted things like the gut-directed yoga flow and the gut-directed hypnotherapy have equal efficacy to this low FODMAP diet. So, you know, for all of my patients, I would never just do diet. It's always got to be an element. If they want long-term benefit, they need it. And I guess it's probably important to highlight that, you know, I am a scientist. I'm all about the evidence. And I historically thought that yoga and, you know, hypnotherapy is a bit woo-woo and, yeah, hippie-dippy. But now I've seen the clinical trials and the data, I'm like, oh my god, I need to, yeah, incorporate this into my clinical practice. So, you know, yeah, I was a skeptic and now I'm converted because there's the evidence there.
Dr Rupy: Well, that's really nice of you to share that because I think that gives us an insight into most scientists' brains. It's like, you know, you need to have a little bit of data there for you to even engage in the subject matter. We had Dr. Robi on a couple of weeks ago, who's a neurogastroenterologist at the Wingate Institute. And she has since become like a proper advocate for yoga and mindfulness breathing and diaphragmatic breathing as well. Is that one of the...
Dr Megan Rossi: Yeah, yeah. Of course, that really can help with bloating. In fact, a lot of the bloating, you know, we've actually scanned people's guts and shown that people who had that big distension don't necessarily have more gas in their gut than someone without the distension. It's just that that's a body way of acting to the kind of the sensitive gut in that their brain, so the messages go up from their gut to their brain to say there's a lot of activity in there. And their brain actually pushes down their diaphragm and their gut muscles actually relax resulting in that distension. So yeah, the diaphragmatic breathing can really help reverse that with bloating. So again, bloating is not all about diet, which people kind of think.
Dr Rupy: Exactly, yeah. And I think a lot of people are going to their general practitioners, obviously after excluding red flag symptoms with the expectation that there is something wrong with their diet and it needs to be further investigated with, you know, stool tests and bloods and everything else. How do you approach, because you talk about this in the book, you've got a whole section on bloating, which again, I'm super excited because I don't think there's any other book out there that's really going for those clinical symptoms that I see as a GP. So now I can start referring people to this book all the time. So when you see a patient with bloating, what are the kind of things that you start off with and how do you create this sort of plan for them to try and figure out what the root cause is?
Dr Megan Rossi: Yeah. So again, in the book I've listed it's kind of like the first line strategies, the second line and the third line. And I literally go through as I would in clinical practice. So I get people to try out these first line strategies. And in the back of the book, there is that gut health action plan. So I hope people kind of write out themselves, I've tried this, tick, it didn't work, or yes, this did work, this is enough for me. So I would get them to have a look at things like, you know, a symptom and food diary just to make sure it's not a food intolerance firstly. Also things like their stress levels, their sleep levels. You know, things like a lot of those artificial sweeteners actually can trigger bloating because they're low calorie because we can't digest them. So they get into the lower part of the intestine. So they can actually trigger a lot of gut symptoms in people and, you know, some people are loading on things like these protein bars and stuff. So as a result, they're having so much of these, which is you take them out, the symptoms are completely gone. It's as simple as that. And even having super large amounts of protein, our body can only absorb certain amounts. And then the bacteria start to ferment the protein and they don't do very good things with protein. So obviously protein's hugely important to get in the diet, but having a really, really high protein diet and low fibre diet is actually not good for the gut microbes. So...
Dr Rupy: Sorry to segue for a second, but side tab, I remember you used to work with the Olympic swimming team. Is that right?
Dr Megan Rossi: Synchronized swimming team.
Dr Rupy: Synchronized swimming team. That's the one. Did you notice any of these sort of effects in them? Because they, I'm assuming they have a higher protein diet or they they thought they think they need to have a high protein diet.
Dr Megan Rossi: Yeah, absolutely. And you know, when I was speaking to them, kind of educating them, actually, you know, looking after their gut microbes can help with their performance. In fact, there's been some evidence highlighting that looking after your microbes or a really diverse range of gut microbes is associated with better performance, athletic performance, obviously. So yeah, they, you know, I did have to kind of talk to them about that and educate them and kind of get them to think a little bit differently. And a lot of those girls actually had a link between the performance anxiety and also their gut issues. So they were kind of already interested around the gut. So it was around changing some of what they were having. So yeah, they were still having quite a lot of protein because they needed it for their really high, you know, muscle mass, but certainly not as much and through natural sources, not having a lot of these supplements.
Dr Rupy: Yeah, I think most people have that disordered thinking when they think about diet in general. And there's something that you kind of reframe quite early on in the book where you try and suggest that people should think about feeding your gut microbiota rather than just feeding your muscles or feeding your cells and stuff. Because your gut microbes are the ones that are going to be responsible for digesting a lot of your food and absorption and...
Dr Megan Rossi: It's all about, you know, being less selfish. We are so selfish if you think historically, it's all about, you know, like what do I want to eat? What's going to be good for my body cells? But actually, we've got this inner universe of trillions of microbes that do so much for us. And if we look after them, they will then help us. If we don't look after them, they'll get a little bit grumpy and won't produce the right hormones and vitamins, etc. So, you know, we need to think of our body like that and respect our body not just for us, but for the microbes that are living in it. And you know, you probably read the the kind of slightly interesting fact that, you know, humans couldn't survive without these microbes. So it is a bit humbling to the human ego that, you know, we need these guys. They actually don't really need us. They can survive without us. And you know, other things like if a female's pregnant, you know, they really worship their body during that nine-month period. And I think, well, actually, we're always growing something inside us. We should always be caring about our body and what we're putting into it because of that.
Dr Rupy: That's a really good analogy. I didn't even think about that. You're always growing something inside your body. So, yeah. Brilliant. So many analogies.
Dr Megan Rossi: So many analogies.
Dr Rupy: You also talk about metabolomics slightly in the in the first section of the book as well. Would you mind explaining exactly what we mean by microbiota and metabolomics? Because I think that's coming on to a lot of people's mindset now.
Dr Megan Rossi: Yeah, yeah, absolutely. So our microbiota is the trillions of bacteria and yeast and fungi, parasites, all that sort of thing together. So the actual live things. And the metabolome is actually the different chemicals that they're able to produce. So you know I mentioned that study where in IBS we were able to predict whether someone would respond to the probiotic or not. We actually didn't find a link with the bacteria. We found a link with the metabolome. So we looked at these volatile organic compounds, so the different metabolites the bacteria produced, and it was that that actually predicted whether someone would respond to the diet or the probiotic or not. And this is a really important point in that the exact same bacteria can actually act very different in different environments. Similarly, identical, I mean, very different bacteria can actually do the same things. So that's why I think a lot of these commercial tests are too primitive in that they're looking at just what bacteria are there. But it doesn't actually say a lot. We need to look at the metabolome of what chemicals they're producing, what actions they're actually, yeah.
Dr Rupy: What do you make of some of the commercially available microbiota tests? So Viome is gathering a lot of attention in the US, and I think they're going to start breaking into the UK market soon.
Dr Megan Rossi: Yeah. Again, I think they're a little bit ahead of their time. So we just need the science to catch up. And a lot of my patients on Harley Street come with all of these tests and I go, look, that is super, super interesting, but that's not actually going to change my clinical practice. I would much rather, you know, look at your symptoms, look at your diet, look at your lifestyle, and that will be a lot more tailored to you than just looking at what bacteria you have in you. Because of those points that the same bacteria can act so differently in different environments. And similarly, the same bacteria, different bacteria can do the same thing.
Dr Rupy: That sort of motto is sort of drilled into us as NHS practitioners, does it change management? And not only is that pragmatic from a cost point of view, but it's also pragmatic from do no harm and not over-investigating point of view as well. Because I think that's what I'm seeing a lot of these days. A lot of people are having genomic tests, microbiota tests, breath tests, food intolerance tests, and it's just, it's sometimes there is a case of too much data and not enough doing anything about it because there isn't anything that's going to change your management.
Dr Megan Rossi: And it creates a lot of health anxiety. So people are coming with like all these red sections going, oh my god, this bacteria is really, really low, fix it. And I'm like, guys, don't worry, like you don't actually need that. You've got this one which can do the same things. So yeah, I'm a big believer of that. I do, like there are some evidence-based startups that are starting to look at this and they're actually doing the clinical trials before they go and, you know, sell to the public, which I think is really important. So it is coming. It's just not quite there yet.
Dr Rupy: Okay. One other thing I wanted to talk to you about, SIBO.
Dr Megan Rossi: Yes.
Dr Rupy: It's like a buzzword at the moment. Everyone appears to have SIBO according to their own. Would you mind doing a little introduction into what SIBO is and what kind of experiences you've had in clinic as well?
Dr Megan Rossi: Yeah, so SIBO is an acronym which stands for small intestinal bacterial overgrowth. And essentially, if you think of our digestive tract, which is that 9-meter long tube from entry all the way to exit, there's four main sections. So we've got our esophagus, like our food pipe, then we've got our stomach, then we have this long part which is called our small intestine, which is like 6-7 meters, so you know, quite a lot of room. And then we've got our large intestine, which is the very end part. Now, in our large intestine is where the bulk of our gut microbes live. Now, with SIBO, it is kind of what it sounds like. Some of the microbes have gone from the large intestine and they've crawled up into the small intestine, which is why it's small intestinal bacterial overgrowth. And unlike the large intestine, the small intestines can't really deal with a lot of that extra microbial, you know, fermenting. So when the bacteria and the yeast, etc, eat our food, our fibre that enters the large intestine, they release gas, which is normal, really helpful for many other things. So it's not something to worry about. In the small intestine, it can trigger that sensitivity, the pain, bloating, and loose stools. Now, what we are kind of still trying to get our heads around is the overlap between irritable bowel syndrome and SIBO. We kind of don't really know where they they differ. And the reason for that is the test for SIBO is is really invasive. So the breath tests are kind of like a, yeah, not a really strong way to assess it. It's just like a piece of the puzzle. People can do these breath tests and then also look at their symptoms, but it's not black and white. What you need to do is actually go into the small intestine and get a sample, then test it for the different bacteria, look at the profiling, etc. So that's really invasive. So it's, it's quite difficult to determine that. But the important thing coming back to how how does it relate to clinic is my clinical practice and what I would say is actually quite similar whether it's irritable bowel syndrome or SIBO. So people don't really need to go and pay for all these expensive tests. If it is SIBO though, and we go through the diet and the diet aspects don't really work, then there is some decent evidence for a specific type of antibiotic, rifaximin, which is very specific for the small intestinal bacterial overgrowth, and it's thought to be not as detrimental. Now, if people were to take that, there's also good evidence to add in some fibre. So the guar gum fibre, there's been a clinical trial supporting that. So, yeah, I think it is an area where there's a lot more research needing to be done. And I think we'll look at diet first, and if people don't respond to that diet, and they do have very, you know, loose stools and a lot of bloating, then I would probably consider whether we need to explore whether it's SIBO. But also things like bile acid malabsorption is also really, really common in people who have IBS diarrhea predominant. Around, the one study showed around 30% of people actually have bile acid malabsorption as the cause of that, and they actually don't have IBS. So yeah, I think we knew in that space, we actually do need to do a lot more.
Dr Rupy: Yeah. And I think, you know, the diagnosis, even though it's helpful in terms of directing management, there's so many overlapping features as well. And I'm sure like, you know, a lot of the studies wouldn't even consider the anxiety, the stresses, and all the other lifestyle factors that could be impacting the reason why they might be experiencing the symptoms too. And the patients that I've had who have been diagnosed with SIBO have always gone down the sort of gastroenterology route. They've had the endoscopy. They've been put on rifaximin. I didn't know about the guar gum additive actually until I read the book.
Dr Megan Rossi: Yeah. But with rifaximin, a lot of them relapse after like four months because they haven't treated the underlying issue of why the bacteria are crawling up. And a lot of that can be, you know, stress or whether actually they've got an underlying condition like diabetes and that's not well managed. And yeah, their gut movement processing is not quite right.
Dr Rupy: What are your opinions on high sugar diets and SIBO and whether sugar is in some way related to SIBO? Because I think there is this underlying belief out there, at least on the blogosphere that it's related.
Dr Megan Rossi: Look, you know, there's many different types of sugar to start with. But if we're talking about table sugar, table sugar is absorbed really high up our intestine. So it doesn't really get down to where the bacterial overgrowth has occurred. But what we do know is that people who have really high processed high sugar diets actually don't get much fibre. So it's not necessarily the sugar per se that's evil. It's the fact that actually they're not getting the fibre, they're not nurturing their gut microbes. And that's kind of the cause.
Dr Rupy: Yeah. I think it's one of those things that it's quite hard to, even myself, to explain to people because they just want that short answer. Should I be eating sugar? Should I not be eating sugar? Whereas it's a whole load of grey out there. It's a whole complex thing.
Dr Megan Rossi: And if you know, it helps you saying, yeah, don't eat too many treats, then fine, even though that's actually not the real mechanism. It's just you can have treats, you just got to add the fibre and have that boringly balanced diet to look after your gut. Now, you know, with SIBO, there's also in that low FODMAP diet, there are certain types of sugars like fructose, so fruit sugar. So if people are having large amounts of fruit sugar, it's absorbed slightly lower down and we're not as efficient at absorbing it. So if we think someone has SIBO, then having, you know, high amounts of fruit is not great. Still certainly can have some fruit. It's just, you know, 80 grams of portion three times a day rather than, you know, eating the whole blueberry basket and things like that.
Dr Rupy: Yeah, exactly. Well, it is a tough job being an academic influencer and trying to distill all these messages, but honestly, and I'm not just saying this, your book does a fantastic job of that. It's rich of information, but it's not overwhelming and it's very, very easy to read. And all those extra sort of things that you've got on your website as well, make sure we link to in the show notes. But thank you very much for doing it. Honestly, it's I can I can tell why it took you so long to write it as well because there's so much in there.
Dr Megan Rossi: Thank you. It means a lot coming from you, Rupy.
Dr Rupy: You can find my wonderful guest, Dr Megan, at theguthealthdoctor.com where you can find lots more information about her new book, but tons of extra resources that she's put in there for people who have the book as well, which I think is fantastic. Instagram, the Gut Health Doctor, Facebook, again, the same, the Gut Health Doctor, and Twitter, the Gut Health Doc. Make sure you get a copy of this book. Honestly, it's going to be one of those books that I refer to patients all the time. It's a fantastic guide for anyone looking to improve their gut health and even explain some symptoms as well. And as always, you can find this information and more at thedoctorskitchen.com. Subscribe to the newsletter for weekly recipes, content, and much more to help you live the healthiest, happiest life. Give us a five-star rating if you like this pod. It really helps spread the love and the message. Make sure you get social with us. Doctors_Kitchen is the tag, and you can find us on Instagram, YouTube, and of course, don't forget to order a copy of my book as well, Eat to Beat Illness and the Doctor's Kitchen. For now, I will see you later.
