Dr Rupy: Welcome back to the Doctor's Kitchen podcast with me Dr Rupy where we're going to be discussing the most important topics and concepts in the medicinal qualities of food and lifestyle. These are some of the things that I wrote about in my first book, The Doctor's Kitchen, blending together the science with delicious recipes inspired by cuisines from around the world. One of the things I get asked a lot about is the assumption that when I talk about food and medicine, I'm largely referring to obesity or cardiovascular disease, but the aim of this show is to demonstrate the intersection between nutrition and lifestyle across the breadth of medical specialities. And that's why today we're talking about diet, lifestyle and the speciality of urology, which actually covers a lot more than just your bladder. I've got one of my good friends, Mr Nish Betty, a urology registrar from London. He's an avid climber. In fact, that's actually how we bonded whilst we were in Sydney. We had a mutual friend who introduced us and we ended up going climbing on your on your time away.
Nish: Yeah, that's right.
Dr Rupy: That is right. And it was Sydney, that was amazing.
Nish: And it was good, hey?
Dr Rupy: Welcome to the show, mate. I'm so pleased that you could come. Let's start with probably one of the most commonest things that you deal with. Stones.
Nish: Yep. Okay. So, kidney stones, a really big problem, extremely painful. Really, really painful. People say more painful than childbirth.
Dr Rupy: The men say that?
Nish: I think probably, I think women are more qualified and they're telling us it's painful. You've got to take it seriously. And it's a huge amount of operating required for for stones as well. So it ends up being a big burden for people, for for hospitals. So, I think there's quite a few established sort of dietary things to do to to try and reduce stones forming. And there's no actual medicine for most stones formation to reduce most stone formation.
Dr Rupy: Before we talk about that, could we talk a little bit about why stones form in the first place and why there might be a genetic predisposition? Because that's kind of like an unknown topic, right?
Nish: Yes, I think it is a bit unknown. I think there's a predisposition, exactly like you said, and if your parents have stones then you're 20% more likely to have stones. But a lot of people just have them without that. And there's no real known cause for most common types of stones. There's a few like the weird and wonderful types that are, you have some sort of gene abnormality and then you'll you'll form those throughout your life, maybe even from childhood.
Dr Rupy: So yeah, the vast majority are potentially due to stress or dehydration is one of the sort of potential factors. But there's also an element potentially with your diet.
Nish: And so there are broadly two types of stones?
Dr Rupy: There's quite a few different types of stones. We describe them in terms of their makeup. The most common types are calcium stones. And then the two types from there are oxalates, phosphates.
Nish: Okay.
Dr Rupy: So, in terms of the dietary advice for oxalate stones, now about 15% of that comes from your diet, your oxalates in your body. So it's not all of the oxalates, but if you reduce that amount, then we usually try and advise people, particularly if they're forming oxalate stones, that will be helpful. They tend to be the hardest types of stones, so they're more of a pain to remove as well. It takes longer to operate on them.
Nish: What kind of size are we talking about?
Dr Rupy: So, usually if they're above about half a centimetre, they start to become a problem. And that's when they can get stuck and they're more difficult to pass without an operation. You know, as a rule of thumb, they can go up to filling your whole kidney as well. So you can you can grow pretty big stones.
Nish: From half a centimetre, that's 5 millimetres, that's when, you know, it's starting to get pain, problematic, all the rest. Or some I've actually seen smaller and very small actually, and they're still creating quite a bit of pain for the patient, right? When would you consider starting surgical intervention? Is it size dependent?
Dr Rupy: There's a few factors. So size is a big factor, but you can also look at the position of the stone, associated infections or obstruction to the kidney. If they've only got one kidney as well, you're more at risk. Interestingly, pilots, if they even have a small stone, are not allowed to fly. So they have a higher sort of intervention rate. So you'll operate on more more often for pilots with small stones.
Nish: Really? Why is that? Just because they're going to be up in the air and?
Dr Rupy: Exactly, because if they're up in the air and then suddenly the stone drops, then they're in real difficulty. Obviously, they're far away from hospital and treatment and they're in charge of a plane.
Nish: Exactly.
Dr Rupy: So I think we're talking about food, weren't we? And yeah. I forgot. The the low oxalate diet is one thing we were talking about. So if you do get those oxalate stones, and people always ask me, patients say, well, what is an oxalate? And we tend to say it's a range of things that can be affected. So tea and coffee, certain nuts, rhubarb, for example, spinach. So it's it's a tricky one to avoid. And what we tend to do is just say, look, are you eating maybe five bags of this type of nut every day? Because that could be why you're getting these oxalate stones, rather than saying try and cut out specifically these things.
Nish: Are there dietetics teams involved with urology teams when patients come and present with specific types of stones like oxalates?
Dr Rupy: That's a good question. In general, no. It's interesting because in our speciality, when we're talking about these diets, generally we just give people advice briefly. And one of the reasons why I wanted to do this is to to look into exactly what, you know, how to make it easier for people to to avoid those diets. And maybe a dietitian for urology would be helpful.
Nish: Would be useful, yeah. Particularly if like, you know, it's in oxalates in such a broad range of different food types, it might be harder for urologists as well to try and identify where in their diets they're actually getting these types of foods and how to replace them as well.
Dr Rupy: Yeah, exactly. What do you do if you're if you're cutting out all of these things?
Nish: Exactly, yeah. Particularly the greens because they're high in oxalates, but they're very good for us.
Dr Rupy: Yeah, exactly. Lots of good in lots of other ways. And people like a lot of tea and coffee and.
Nish: Is that related to the dehydration aspect as well, do you think from the tea and coffee?
Dr Rupy: I think we ask people when we say just to be hydrated, we ask them to drink about three litres of water a day. So that's above the normal amount that anyone would drink. It's quite hard to do.
Nish: Absolutely, yeah.
Dr Rupy: Really is hard to do. And they need to be drinking it throughout the day.
Nish: So you can't just have three litres in the morning?
Dr Rupy: Yeah, exactly. So try and stuff that down in one go. We tend to say like build it into your routine actually. So that maybe first thing when you wake up in the morning, you have a big glass of water. Every time you have a meal, you have one before, one afterwards. Every time you go to pee, maybe you have a glass of water afterwards, you know. So that way you're drinking through the day and spacing it out.
Nish: Absolutely. That's one thing that I actually got into when I was a junior doctor because as you know, you pretty much don't get a chance to stop when you start at like 7:00 or 8:00 in the morning whenever your ward round is. And then I remember getting to like 2:00 p.m. and thinking, wow, I have not had anything to drink and I don't feel like going for a pee either. So there's something, a bit of a disconnect here because I'm looking at patients that haven't passed urine for like six hours and that's when we start thinking about what's going on.
Dr Rupy: I think generally people seem to be much more aware of it in hospitals now as well. You know, people are always carrying bottles of water around with them, these little plastic refillable ones. And I think that's good. And I think if you're a stone former, then you're going to have to take a large one of that with you and it's going to be hard in certain jobs, I would have thought, but.
Nish: Absolutely, yeah. Have you managed to with any patients of yours actually reduce the formation of the stones just through hydration and some simple measures like that?
Dr Rupy: It's really hard to quantify. We know that this works, but you wouldn't really be able to say one way or another, I think. We do have ways of checking on people though when we send them off for a test and then you can kind of see if they've been doing that in 24 hours, if they have how much they're actually producing. And then you can say, well, you're not producing what what we know will help. What you do find is perhaps in the summertime when people are more dehydrated and people aren't catching up with how much they should drink, then you get more stones usually.
Nish: So we're coming into stone season.
Dr Rupy: Yeah, stone season. Um, so that um, that was talking about oxalates anyway. The other things that will help then was a low protein. Generally avoiding all kinds of protein helps with all stones. Something that you can take rather than avoiding, so far we've just been talking about avoiding, but often stone formers have a low citrate in their urine. Citrate can be just found in fruit juices or even just like a few drops of lemon juice. You know, a few drops every day can essentially help stop stones binding and forming so much. That can be a useful thing to do and something else we advise when you're having three litres of water, it probably makes it palatable to have some citrate.
Nish: Some citrate into your foods. Yeah. I mean, having those different sources of citrus fruits into your diet as well is just generally healthy for you. It's another source of phytochemicals that you get. But it's quite interesting to know that citrate has been singled out as an element in the diet that can actually reduce stone formation.
Dr Rupy: It's a useful thing to sort of top up and then help reduce that stone formation.
Nish: And that actually reduces the number of stones that these particular stone formers will.
Dr Rupy: Yeah, that's right. Yeah.
Nish: Have you had experience where you've topped up citrate in a supplemental form, I'm assuming, rather than just diet, or or maybe just through diet, I'm not too sure, but where that's actually had a significant effect on stone formation?
Dr Rupy: It's difficult when someone's not forming stones to actually say to because we don't see them. We tend to see them when they, you know, when they're actually having a crisis, having a stone stuck in the ureter or passing one and then lots of pain coming into the emergency. So, I guess that's the difficulty with studies on stones as well. You can't really see what's not happening. But these dietary things we give are to try and prevent stone formation, but I think also you get the advantage maybe, this is a theory really, but of forming smaller stones. You know, so if you are prone to form them, maybe you'll make a smaller one, or maybe it will grow less quick. So that's maybe the sort of the advantage, I think, if you know, you make your operations or passing the stones a bit easier.
Nish: So a lot of people might assume that if you take calcium out of the diet, that could help with reducing the formation of stones given that calcium is a component of the stones itself.
Dr Rupy: Yeah, that's a good one to debunk because we know that most stones are calcium, but actually they found that if you try and reduce calcium in your diet, you increase the chance of forming stones.
Nish: Right.
Dr Rupy: Which is, yeah, which is a bit bizarre, but it's just one of those things. It's the other component of the stone that's more important.
Nish: That's really interesting. Do you reckon if you reduce calcium from your diet, it might upregulate your body's natural homeostatic mechanisms to increase calcium?
Dr Rupy: Yes, that could probably be part of it. It's also to do with the binding. So calcium in your diet tends to sort of bind the other the other components. So for example, oxalates, like we spoke about before, then you'll you're less likely to have it hanging around in the kidneys and forming stones.
Nish: Exactly. Right. Yeah. So calcium can have a have a protective effect on the oxalates. Got you.
Dr Rupy: Urates was the other thing I was going to mention. So uric acid, which is similar to high levels that can give you gout. So it's purine rich food such as food with meat, fish, anchovies, crabs, herring. So lots of stuff that you're recommending in your book and generally, I know you're looking at me like, why are you saying don't have those?
Nish: Yeah, well, I mean, I think the excess of these certain foods may be something that you want you might want to watch out for. And certainly, according to Mediterranean diet principles, things like oily fish, mackerel, anchovies, you know, we're not saying have those things every single day. We're saying like, you know, have at least two portions per week. Or you can also get similar sorts of omega-3s from different plant-based sources as well, like chia and walnut and algae, flaxseed, that kind of stuff. But that's really interesting to know that these are high in purines that can lead to certain types of.
Dr Rupy: Yeah, gout used to be seen as a disease of excess, didn't it as well? So you know, you have obese people with, you know, a really high red meat, red wine sort of intake and that's what or beer intake as well and you know, people would know that was the likelihood of forming gout. And even traditional medicine, people would associate that and then try and to cut those things out. But for for us in terms of stones, we know that sort of uric acid stones and reducing those levels will will help. So that's pretty much everything in terms of our stone diet tonight.
Nish: Yeah, yeah. I mean, that's super interesting because essentially what you're what you're heightening people's awareness of are things that could potentially exacerbate stone formation from a variety of different sources and things that you can introduce into your diet as well, like citrate is probably the main thing and hydration as well. Those are the two key things. But ultimately, when you have a nutrient dense diet, you've got all the different sort of collection of phytochemicals that you get from vegetables of different colours, as well as judicious use of meat products. So reducing your meat content, that can actually have quite a positive impact on on stone formation.
Dr Rupy: Yeah. Since I've been in urology and started working in hospitals, I've in when I've been in clinics, I've heard consultants giving these talks to patients and saying, look, this is the diet you need to follow. It's in our British guidelines for surgical guidelines, you know, there's information leaflets we give out to patients as well. So I think it's interesting now that, you know, to combine that that people are so much more food aware, but actually that's been happening for for stone formers for a while, exactly.
Nish: Yeah, exactly. And I think it's it's it's good that we, you know, heightening people's awareness of these particular certain diets. As I get asked a lot actually about lots of different ways in which people can utilize diet in certain ways. And my general advice is to look at the whole bodily system rather than, you know, doing things to to essentially try and treat one aspect of the body. But this is quite interesting in that there are certain, there's advice specifically tailored towards stones.
Dr Rupy: It's it's I think people sometimes they find it maybe a bit strange patients when they they're coming to a clinic and they're, you know, they're in a medical clinic, they want medicine. But in when it comes to stones, there's generally no medicine that we give them to prevent stone formation. And we try and just tailor a diet to them. And we do have that sort of personalized aspect. So that was the general dietary tips I've given you, but if we collect a stone, so if we usually if we operate on them and then we take a fragment of the stone, we can send that for analysis. And then if we find out that they've got a uric acid stone or an oxalate stone or a certain type, then we tailor the diet even more. We say, look, you're forming this type of stone, so your diet needs are specifically this.
Nish: Brilliant.
Dr Rupy: You know, stop eating 10 bags of nuts a day, you know, today or whatever it might be.
Nish: So the episode is called If Your Bladder, and this is one of the most commonest things that you see in clinic, right? Lower urinary tract symptoms.
Dr Rupy: Yeah, that's right.
Nish: And what what do we actually mean by that?
Dr Rupy: Lower urinary tract symptoms are it's it's basically a group of different types of issues that people have with their bladder. And that can be defined by lots of different terms for men and women. And it can be like they're not happy with how much frequency they have or urgency, for example, or that they're not happy with the flow.
Nish: Urgency is that sensation of needing to go?
Dr Rupy: Yeah, exactly. That sort of sensation of needing to go for a wee, having to run. We see people who've tried medicine for that usually and are still having problems and then they come to hospital and they, you know, see our specialist advice. At that point, you do assume that usually they've done everything they can in terms of lifestyle measures. But actually people aren't very good at reviewing that from a bladder point of view. So rarely, but occasionally we'll find people who are doing things that they could really change within their diet and lifestyle. Usually they'll be done by really good GPs before they get to us.
Nish: Really good GPs.
Dr Rupy: I mean, on the most basic level, avoiding caffeine. So caffeine is an irritant for your bladder. And occasionally you'll see someone in the clinic who's drinking like 10 cups of coffee a day. Or the other one that's interesting is green tea, because people don't realize that that has a lot of caffeine in there as well. And because they know it's so good for you, people sometimes will just drink that as their only fluid and then wondering why they're so irritated in the bladder the whole time. So that's the first thing we'll sort of look at and try and advise against. Along with that and other lifestyle sort of measures like pelvic floor exercises, bladder training, you can actually get about 50% people improving.
Nish: Just from doing the exercises, avoiding caffeine, maybe.
Dr Rupy: Can you describe some of the exercises for the listeners? If you're if you're having a wee, try and stop yourself midstream. So that's a good way of making sure you're isolating the right muscles. And then if you know that you're using those muscles to stop the stream, then you can try and bear up and sort of pull them up separately to when you're having your wee. And you should be doing that, you know, during the day, maybe if you can fit it in 10 times a day or something. We say like 10 bursts, short, short and fast, sort of contractions of that muscle.
Nish: This is a question I get asked actually. Are there any benefits of doing these particular pelvic floor exercises generally, even if you do not have bladder symptoms?
Dr Rupy: I think probably it is in terms of training any muscle, I think it'll be useful. And interestingly from our point of view, we try and get all of our patients to do it. You know, and even if it doesn't work, it gives you better results if you do operate on them. But what's interesting is that you can just fix your problems with with just doing, you know, fix your bladder problems with those simple measures.
Nish: Exactly, yeah, with doing these simple exercises. And I think a lot of people, I've certainly had experiences with patients in the past where they're resistant to doing these exercises because they think it's quite futile. But as you've said, you have to get them to buy in.
Dr Rupy: The difficulty with it, you know, that's probably why it fails because it requires that commitment from the patient.
Nish: Exactly. It's that behaviour change that you want to try and and and get over. And, you know, as you're saying, 50% of people that do these simple lifestyle measures can actually have an improvement. I mean, that's 50% of people that don't need to be on these medications, many of which have side effects.
Dr Rupy: Yes, exactly. Particularly with the bladder, I think, and you know, there's so much of it is psychological and so much to do with what you're what the fluids you're having and and the muscles around there that you you could just improve yourself.
Nish: Yeah, and the timing of fluids as well, right?
Dr Rupy: Yeah, and the timing of fluids. I think as well, you know, not drinking in the evenings, for example, if you're getting up a lot overnight, seems very simple and obvious, but you sometimes find people, you know, who maybe just have a beer just before they go to bed or something or a big cup of tea and then they wonder why they get up overnight and you know, it's it seems a bit patronizing to say the obvious stuff sometimes, but that you know, it can just be someone reviewing your lifestyle with you and you know, and then helping without just giving medicine always, yeah.
Nish: Totally. And so these sorts of lifestyle measures you do before entertaining even supplements and stuff like that, right?
Dr Rupy: Yes, yeah. I mean, generally we try and do as much as we can possibly with this first. And what I try and say, and I heard one of my consultants, you know, phrase it like this once, and I've I've used it quite a few times, is that we could try doing everything together to make your bladder perfect. You know, maybe this has taken a while to happen, but if we do everything, including lifestyle measures and dietary things, as well as maybe we'll give you a tablet for six months, and then see where we are, and then maybe you can at that point, you can think about stopping the tablet and then going back to having coffee occasionally and and so on and finding out what works for you.
Nish: Almost like giving your body a reset to essentially sensitize itself back to a normal medium.
Dr Rupy: Yeah, and I think also giving it that that six month window means that you're not committing someone to a lifetime of their tablets to fix the problem, which is, you know, I'd rather, I think people generally would rather not be sort of committed or independent on tablets.
Nish: Yeah, because I see plenty of, unfortunately, of the older generation being on these sorts of tablets for a long period of time, and they have so many different side effects, first of all, but also interactions with other medications as well that can be quite severe. So it's really important to get them to buy into all the different lifestyle measures. Something I've seen quite regularly actually in my clinic is patients coming in with recurrent urinary tract infections, and they're on antibiotic after antibiotic. And unfortunately, from what we know about antibiotics as well and its effect on the gut microbiome and how that can have detrimental effects on far-ranging different aspects of our health, let alone microbial resistance, it's something that we are being much more reserved about prescribing. However, with these sorts of patients, it can be very problematic, right?
Dr Rupy: What you've said is is the biggest point, I think, and the biggest problem at the moment in the hospitals is antibiotic resistance. And we're seeing more and more people just have resistance to the first line, even second line antibiotics. And then, you know, you're running into more, you know, difficulty in just treating simple infections. Recurrent UTIs is an interesting one because any sort of alternatives will really help. So any non-antibiotic treatment and as much as you can do with supplements or lifestyle and things, I think are is what people are looking at now.
Nish: Yeah, absolutely. And you've done some research by going to a few sort of like, uh, uh, supplement, uh, shops and stuff like that. And what are your, yeah, what are your takeaways from that?
Dr Rupy: Yeah, so to like, so to prepare for doing this today, um, I thought I'd speak to other urologists, so my consultants and registrars and make sure that I was saying what the general consensus is and what other people are saying in clinic and so on.
Nish: And what's evidence-based and yeah.
Dr Rupy: And um, I also went to a health food shop and asked them for all their urology medication or supplements that they had.
Nish: They must have given you a hard sell as well. Not knowing that you're a urology.
Dr Rupy: Yeah, they did. And they had to go and call someone from the back room to first of all to be like, I'm not quite sure what he's asking for. This guy's got a difficult customer. Um, but so I looked at it and it was interesting because there were a couple of different supplements for each type of thing that we're used to suggesting. So like one example, we suggest certain types of cranberry capsules, or I have in the past. And in the shop, they had two or three available. So then it's interesting to see the the variety there.
Nish: Yeah.
Dr Rupy: So I I basically got a quote here from the European guidelines, not to make it too heavy, but I just thought I'd say this because I think it's relevant to to what we're talking about. So basically, the extracts of the same plant produced by different companies do not necessarily have the same biological or clinical effects. Therefore, the effects of one brand cannot be extrapolated to other brands. In addition, batches from the same producer may contain different concentrations of active ingredients.
Nish: So that says a lot, doesn't it? That basically says you can't trust one brand from another, and you can't trust one brand. Even if it was the brand that was in question or has had some clinical studies looking at it.
Dr Rupy: Yeah, exactly. Like you said, so even if you're taking a supplement from one brand, then because it's a plant-based extract, it may not be as good as the next brand and may not be even consistent. So I thought that was interesting and that shows why it's so difficult to do research on the supplements because you can't be sure what you're testing from time to time. And therefore we don't know exactly how good some of these things could be, or whether they do anything at all.
Nish: It's almost like, you know, getting back to the root cause of why these patients are having UTIs in the first place, which can be very varied from one patient to the next. You know, somebody could have a sugar regulation issues, they might be diabetic. Some people might have hygiene issues, they're wiping the wrong way, for example. And there are some simple reasons as to why there might be differences as well as some more complex ones as well that really pertain to the ecosystem of that patient's bodily environment.
Dr Rupy: That's right. And we see maybe two different sort of types of infections as well. There's maybe the recurrent type, the same bacteria organism again and again and again, or people who get sometimes different types of bacteria infections. Most commonly the organism is going to be E. coli because of, you know, being close to that source, that infection. The only thing that I'd say is really especially beneficial is D-mannose. So D-mannose is the sugar that's has antibacterial properties within cranberries. And there is evidence that shows that basically having supplements of that, so that's actually one gram twice a day, that sort of dose, can reduce infections. And it's not an antibacterial, so it doesn't actually kill the bacteria, but it stops E. coli particularly binding to the bladder wall. It makes it sort of puts a lining between the bacteria and on and on the bladder wall as well.
Nish: That's really interesting actually, because there are some sort of gut-focused treatments as well that prevent recolonization of certain bacterial types in the intestines as well, using a similar sort of mechanism to what sounds like D-mannose that I haven't actually come across before. That's really interesting.
Dr Rupy: I think it's one of those things where, you know, people will will come to you and or, you know, women will patients will say, you know, I'm doing the best I can, I'm drinking a couple of litres of cranberry juice a day or something. And you have to say, well, that's definitely not going to be helpful because to get the sort of the actual active component, you're not really doing the right thing. So the only amount of cranberry juice that's recommended in in our leaflets is about 400 mils, so it's maybe a glass. But actually, it's probably better if you're having the D-mannose itself, which is the the active component.
Nish: Yeah, and there's some trials looking at D-mannose as well, are there?
Dr Rupy: Yeah, so that's there's a trial which is, you know, published and it's it's also mentioned in the European guidelines again, which is kind of our gold standard for for treatment really. And it's shown actually there that using that regime, they had almost equivalent results to using an antibiotic as well.
Nish: Wow. So that's quite interesting.
Dr Rupy: That's very interesting, yeah, the fact that you can what at least in this very small scale trial, I'm assuming, you can get away without using an antimicrobial, which can have negative side effects compared to D-mannose.
Nish: Yeah, and then, you know, you avoid that resistance problem as well.
Dr Rupy: Awesome. Probiotics. That's something I get asked about a lot, right? So probiotics, yoghurts and Actimel and all the other brands.
Nish: Exactly. So we we most consultants I think would advise lactobacillus. There's no convincing benefit from that in in terms of a meta-analysis, but there is sort of weak evidence to say it helps. And I think, you know, there's absolutely no side effects really to having that. So again, with all of these things that we're talking about, the fact is that, you know, you may get a small benefit, but you're not really going to get too much harm.
Dr Rupy: I think the forefront of all of our minds is first do no harm. And, you know, if you're going to be introducing probiotic foods and prebiotic fibres to encourage a good microbiome, you know, we're going to be having positive side effects instead of negative within reason. So, you know, having all these different things and potentially even trialling some different sorts of probiotic species may be of benefit. It's worth a shot. That's what I like to say to patients for sure. Again, on the same topic of doing doing no harm, you're not going to do any harm by reducing the amount of added sugars in your diet. And if you're actually concentrating on a nutrient dense diet that has got lots of different prebiotic fibres as well as perhaps probiotics that you can find in the form of sauerkrauts and kimchis and different sorts of yoghurts and kefirs and that kind of stuff, you may be putting your body in the best environment where it can actually look after itself and prevent these recurrent UTIs. It's worth a shot. Again, it's worth a shot. There isn't, unfortunately, there isn't that large scale nutritional evidence to suggest that this is something we should be giving to all our patients. But in the grander scheme of things, it's definitely going to be something that is going to be positive for you, if not, you know.
Nish: But there are, I mean, there definitely are trials showing that, for example, what we're talking about obesity and controlling your sugars and, you know, better diabetic control. There are trials to show that that helps almost all of your health. Not just recurrent UTIs, but all of the stuff we've been talking about, even stone formation, obviously the most obvious ones are cardiovascular disease, but it's interesting that, you know, just losing weight, controlling your sugars can help almost everything, every medical problem.
Dr Rupy: Absolutely. And anecdotally, you know, from having patients, I mean, we see a lot of patients in GP with recurrent UTIs, unfortunately. Just by changing the diet, improving their HbA1cs, the marker of their glucose over the last couple of months, improving their their general well-being markers, that's waist to hip ratio, you know, you can have massive effects. And I've actually had some patients that have reduced the number of UTIs they have per year by just changing their lifestyle as well, the way they approach their their health.
Nish: Yeah. And I mean, that's what some of the evidence shows, so that's that's interesting. That's good. Nice success story there. Pat on the back. One of the most controversial areas I think is bladder pain syndrome. This is a very complicated issue that you, I'm sure you have, I mean, you have clinics dedicated to this, right?
Dr Rupy: Yeah. So, um, I worked in a in a hospital where they had a very high incidence of interstitial cystitis, which is the sort of the older term maybe for bladder pain syndrome. I ended up reading a lot into the guidelines and there's a lot of research about it and there's a huge spectrum. And essentially we're looking at people who have pain in the bladder and it's like a chronic pain problem, so ongoing pain without an infection, without an obvious cause. So there's not a stone again or or a tumour or anything else like that in the bladder that's causing it. And so they're really hard to treat because it's it's a situation where, you know, we can't find a cause, but someone's telling you they're in pain. And other than giving better painkillers, there's there's limited options. We do have some surgery that we try and do, and again, it's just a it's a very difficult area. So before we get there, we try and do as much as possible to empower people and there is essentially a diet again that we advise and that's why I wanted to mention, but this I I would be honest is has not got the strongest evidence because there's such a variety between patients and so many different factors that could be happening here.
Nish: Yes.
Dr Rupy: But I think it's interesting to to put it out there and it's available on on websites as well. Again, on the our sort of guidelines, our British surgical guidelines for urology or and the European guidelines. And the main things which may irritate the bladder is acidic, spicy foods and fruit juices, for example, are sort of acidic foods. And interestingly, like cranberry juice, if you're having cranberry juice for your UTIs, that's one thing, but actually, if you have bladder pain syndrome, it may be causing pain and problems.
Nish: Could that be related to the sugar content at all of these fruit juices as well as the fact that?
Dr Rupy: I think it's more the acidic side of things as as far as I I have it documented, but I don't think, you know, excessive sugar obviously is not going to help either.
Nish: Exactly, yeah, from an inflammation point of view and you think about like the biological processes of why people experience more pain as well.
Dr Rupy: So the only advice really that we can have away from painkillers for these patients is to try to do what they can with their diet, which means in bladder pain syndrome, trying to avoid spicy foods, acidic foods as well. And interestingly, that can include cranberry juice. So although that might be good for urine infections, the acidity in that may be detrimental for bladder pain syndrome sufferers.
