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Rowena Field is a Physiotherapist and Researcher in Chronic Pain and Nutrition. She is also involved in the STEPP program which focuses on 'Solutions, Tools & Education for Persistent Pain'. Today, Rowena talks about the role diet has on pain sensitivity and her research on low-carb and keto diets for pain management. Listen to learn the role of glucose and ketones in body inflammation and the changes you need to make to have a positive impact. Click here to learn more about the STEPP program Run Smarter YouTube Channel Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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On today's episode, change your diet to change your pain with Rowena Field. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life. But more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers. and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default, become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence, and start spreading the right information back into your running community. So let's begin today's lesson. I have just released the most value packed and fun video I've ever made over on YouTube. I think I'm enhancing my skills every single time and this one, I don't know, I just had a lot of fun with it. You may have seen last week I put onto social media, what is your first marathon mistake? And I put onto a several bunch of Facebook groups and even just yesterday at the time of recording, you may have seen a little snippet to this video. marathon mistakes and I pieced it all together, put them all into categories and because I got over 230 responses on those Facebook groups, I titled the YouTube video, 230 first marathon mistakes in seven minutes. And if you're anything like me, I had a clear idea of what I thought the number one first marathon mistake would be and it came in at number second. So I was super surprised and I'll leave that as a bit of a teaser. And you'll have to go check it out in the show notes. There is a link to the YouTube channel, so you can go check that out. Or you can just go onto YouTube and search run smarter with Brody sharp. And I'm trying to win you over. It's kind of like a bit of a game for me. I'm on a mission to win some of you over onto YouTube. And I get that some of you only listen to the podcast while running. Totally get it. And that's some of the feedback that I have received, but I wasn't big onto YouTube. I wasn't. much of a fan of YouTube before studying it myself and seeing if I want to get onto the platform and see if it was really for me. But now I love it. I subscribe to a whole bunch of running channels and I am learning a ton. Finding the right channels is, I guess, might take a bit of time finding the ones that sort of resonate with you the most, but I follow several running channels now and I'm learning a ton and it's just a way to upskill your running. Just learn more about it and you're a run smarter scholar, so you obviously want the right information. So like I said. I'm trying to sway a lot of you. And if you go check out this one video and see if you like it, see if you can see the benefits moving forward and listening to or watching, I should say. One or a couple of videos per week. It might be worth your benefit. Okay. I've been dying to get this episode out for you to listen to ever since while we recorded this interview several weeks ago. And it was such a great conversation. I'm like, God, I had all these episodes already scheduled to go out and like every week I'm like, okay, when's the time to. release Rowena's episode and now is the time. So Rowena is a physio, a researcher and has a personal interest in chronic pain management and she's also completed a PhD researching chronic pain and nutrition. She's a part of the STEP program with two P's which is Solutions, Tools and Education for Persistent Pain and she was a wealth of knowledge. If her name rings a bell, it came up with my conversation with Peter Bruckner. He said, hey, check out Rowena. She is doing research on changing people's diet to a low carb diet and influencing, or the influence it does have on people's pain. And so today we dive into, first of all, her curiosity, like why look at diet and pain and where the connection is between the two, but also what the keto diet or a low carb diet does have, what the role of glucose and ketones and. inflammation, anti-inflammation does play in the body when you make those changes. And then we have a dive into her study. So her research study that she conducted, looking at taking a bunch of people with pain, putting them through a change in diet and sort of separating them out into different groups and seeing what the changes were in their experience, in their pain levels. Okay. Without further ado, let's dive into my conversation with Rowena. Rowena, thanks for joining me on the podcast today. My pleasure. I am really excited about this topic. Uh, it's quite unique. It's something I hadn't, I didn't think I'd be talking about on this podcast until, um, Brooklyn, I sort of mentioned it and I was happy that you agreed to jump on. So if for those who aren't familiar with you, would you mind just giving a, a little intro about who you are, where you're from and, uh, what you're involved in? Yeah, sure. So I'm a physio. I've been a physio for. long time now actually I've got my 30 year medal from the a physio association yesterday in the past so I've been a physio for a long time and I currently work on New South Wales south coast I live at Jervis Bay which is sort of near Nowra and I work with a psychologist and we run a chronic pain management program so we've lived on the south coast for a few years now probably 15 or 16, but prior to that I was a sole physiotherapist in Cobar, which is out back New South Wales. So I did a lot of underground mining stuff and all sorts of off health and safety. So I've got quite a diverse background of all different sorts of sorts of things, but my current focus is pain management and specifically nutrition related to that. With trying to connect the two, it's interesting having pain and diets and a lot of people might not, you know, make a connection And so I thought we'd start off with why your particular interest in that and how is there a link between the two? Well, I guess it's one of those things where personal experience will land you in a spot where you have to start looking at things. And I guess the reason why I ended up in chronic pain management was as a physio, I ended up with chronic pain. And so I had a back problem developed when I was pregnant with my second child and it was intermittent in between that and when I had my third child. By the time I had my third pregnancy I had this ongoing lumbar spine problem that I just couldn't get right. I went to see all the cool kids in physio land, all the gurus out there that were running courses and all the rest of it to try and fix my back problem and nothing seemed to make any difference. It was one of those things where I'd reflect on all the things I was telling people that they should be doing to get their backs better and I was doing it for myself and it only seemed to make me worse. So I sort of come to the conclusion that either I was the worst physio out there and had no idea what I was doing or I didn't really understand this pain problem that I now had. And ultimately I ended up in a lovely neurosurgeon's office in Sydney who... basically said, well, I need to do two level disc replacement if you ever want to get rid of your back pain problem. And at the time, you know, I'd sort of totally convinced myself that, you know, those discs were the problem and if they were just whipped out and some fancy new ones were put in that would solve all my problem. And I guess fortunately for me, I wasn't actually in a health fund for that at the time. And so the surgeon said, go away for a year and when you're eligible, come back and we'll do that surgery. And so a year came and went and I still was. no better, but was profoundly scared having that surgery done by that. Of course. I started to look a little bit more into, you know, what, what is the current research around chronic pain? Cause obviously I don't get it. You know, cause what I'm doing for myself and what everybody else has tried hasn't fixed the problem. Medication doesn't seem to do anything. I've done all the exercises. Nothing seems to work. I don't understand what's going on. And I guess again, lucky for me, it just so happened that one of the premier researchers in pain neuroscience at the moment is a guy that I went through uni with. So Laura Mosley that you've probably heard of, everybody knows Explained Pain, I went through uni with Los. That sort of, I guess, piqued my interest to sort of find out, okay, well now he's this you know, he's this famous neuroscientist. And, you know, I remember him from uni being a dag turning up to lectures with no shoes on and wild hair and all the rest of it. I thought I need to understand what his research is about at the moment because he's coming up saying different things now to what I understand to be true about what I thought pain management should be about. And so I guess I sort of fell into that hole of explained pain and looking at all of the research that's now coming out looking about how, well, pain is really a... It's a protective device and it's our brain predicting what's gonna happen in the next instant and it's trying to scramble and do things to protect of which pain is one of those protection mechanisms. And it's not really all that, it's not really telling you anymore what's going on with the structures and the tissues anymore. It's now a separate problem. It's like we've got a problem in the nervous system as well as what used to be a problem in the structures that might've been hurt in the first place. And... That was a totally different way of thinking about things. I hadn't even contemplated that. As a physio, I was very much, if your scan said you had a disc bulge, then you should be going off to see the neurosurgeon and do these back exercises. And if that doesn't get better, well, I don't really know what to do for you. And I guess at that point, I sort of started to learn all about that approach and change what I was doing and stop being so structure-focused and started then looking at really what... what did I believe was going on in my body and how was I thinking about the structures and the implications of it. And I changed all of the way that I was approaching it. And then over the course of the next six to 12 months, I fixed my back pain problem. I've run a half marathon since then, I don't have any back pain anymore. And so it's one of those things where, if I went and got a MRI scan done, I'm sure it still doesn't look any prettier than what it probably did the day I sat in the neurosurgeon's office. But... just because a scan doesn't look pretty doesn't mean it has to be the thing that's actually driving the pain experience that somebody's having. And I was the perfect example of that. You know, I don't have any pain anymore, but structures still probably don't look all that fabulous, but you can certainly get back and get functional again and reduce your pain experience and your sensitivity within the nervous system by changing the approach. And so that's sort of the clinical space that I live in at the moment. And I guess in terms of how do I link that in with diet, well... Diet was another parallel sort of interest that I had because I was always struggling with my weight. I was a chubby teenager and always trying to lose weight doing the, you know, whatever the latest diet was, you know, the low fat in the eighties and aerobicsing away and all the rest of it, trying to manage my weight. And so I was always keen to try and understand, well, you know, what diet's going to be best to help me manage my weight. And it just so happened that I came across low carbohydrate diets and got interested in that space. And because I guess... I sort of enjoy looking at the scientific background of those sorts of things. I started to delve a little bit more into low carb diets and ketogenic diets and what was the physiology behind those and started to hear a lot about, well, they manage inflammation and they do all these things. And it sort of dawned on me one day as I was sitting in one of the pain conferences that I was at, I was listening to some speaker talk about, you know, some new... drug that was out that was trying to target specific molecules within the inflammatory cascades and then my ears pricked up because they were the same things that were being talked about over in the ketogenic diet space and I'm thinking, how in a minute you guys are using drugs to try and target those processes and over here we've got natural way that we can be targeting those processes by changing what we're eating. You guys should be talking to each other." And there was none of that happening. And I sort of thought, oh, well, there's got to be some research out there talking about how diet is influencing pain outcomes. And so I started doing a bit of research and there was none, funnily enough. And so I ended up doing a PhD on it just to try and join those dots. And so that's where I am now. Excellent. Wow. What a story. And most people... that have listened to the podcast. I've done several episodes on pain science before, and I've interviewed pain scientists and we've sort of got the idea about the complexities of pain and how a lot of it is like this psychologically driven state. And while it has psychological influences, not just physical damage, um, but trying to make that leap to what you're eating is like just that, that next step to try and comprehend and. I guess another little attachment in the whole entire complexity of pain. And you sort of mentioned the responsibility of inflammation being in the body and a low carb keto looking diet may look at reducing that inflammation. Um, you sent me a video of you talking about this sort of stuff, um, prior to this interview and you, you mentioned the role of like glucose, maybe having too much glucose and what sort of that does to the body and then once you enter this ketogenic state and having ketones, that also has another role and responsibility in the body. Can you maybe just explain to, in layman's terms, exactly what that does, what that does to the body and then how that can link to pain? Yeah, sure. So... If we're thinking about a low carbohydrate diet, you're sort of doing two things. As you mentioned, you're reducing the glucose and just reducing glucose in and of itself has impacts physiologically or metabolically in the body. And you're also switching the fuel source over to fat. And when fat gets broken down into ketones, that also has an effect on the body as well. And so if we wanna try and link that into how that might influence pain, well, the problem with with having a situation where we're getting spiking glucose all the time is that glucose is a bit of a naughty molecule. It likes to stick itself to protein. So we've heard of glycation. That's what happens when the sugar molecule or the glucose molecule attaches to a protein. And when that happens and the protein doesn't quite function the way it should be. And we're often... I guess aware of what happens is something like diabetes, and we hear about the measuring like their HbA1c, which is just a measure of how much has the glucose stuck to the hemoglobin or the protein in the blood. But it doesn't only stick to proteins in the blood, it sticks itself to proteins in your tendons and your ligaments and your nervous system. So it has other implications in terms of how that the quality of those tissues then, that you know, you know, it can affect how well they function. And I guess that's probably one of the important things to think about is we're looking at not only the inflammatory environment that the structure might be living in, but we're also looking at the quality of the environment, the structure too, and both of those things are influenced by the things that we eat. So that glucose as well as potentially being a problem like that, it also, it can stimulate enzymes in the cartilage that cause it to degenerate and become inflamed as well. And just the fact that we have spiking blood sugar going up and down, those spiking levels are also an inflammatory process. So having a diet where sugar is going up and down all the time does set up this inflammatory sort of loading situation. which is then problematic when we're thinking about, you know, a pain problem, when we're looking at the structure that has to live in an environment that's a little bit more inflamed than what it should be. So part of, I guess, the pain story is just reducing that the glucose can influence the pain outcomes from that perspective. And then the flip side to that is that when we're using fats for fuels instead and we're breaking those down into ketones, those ketones They are an energy source, so they act a little bit like glucose traveling around the blood and all the cells can use that as an energy source. But as well as the energetic side of things, they are also a signaling molecule. So they act a little bit like a hormone that floats around in the blood and when it gets to target organs and target mechanisms it does certain things. And there's two really important things that those ketones do when we're trying to relate this to our pain story. That is one is they block inflammatory pathways and they also, they're epigenetic signalers for various things as well. So by reducing the precursors for the inflammatory pathways, that helps to block down the inflammation. And that was the mechanism that I heard right back at the start, we were talking about what I was listening to in conferences and that's the sort of mechanism that. you know, pricked up my ears to begin with. So hang on, the beauty of what a keto molecule can do is it blocks something called the NLRP3 inflammasone. And it's sort of like the big parent upstream molecule of which lots of other different inflammatory pathways come from. So it's like you're sort of going back to the source a little bit and reducing a lot of the different inflammatory pathways that can exist. And the other thing that they do, I was mentioning before in terms of signalling, is that they can... affect the sensitivity within the nervous system. So that's another problem that we've got with chronic pain is that the nervous system is a little bit more sensitized than it should be. And so ketones seem to have this ability to just help to bring that back into normal levels. So when we look at how... sensitive and nervous system should be, it's sort of a Goldilocks zone that it should sit in. We don't want it to be sitting too high otherwise the nerve can fire all the time and we don't want it to be sitting too low otherwise it's too hard to get the nerve to fire when we need it to. And so what happens with chronic pain is it tends to sort of sit up on that high level so it's tending to fire more easily than it should. And so... we know that the ketones seem to bring that back down into a more sort of stable level. And we've known this for a long time. There's been a lot of research done around ketogenic diets in the past as a management tool for epilepsy. So if you think about epilepsy as sort of being the end of the spectrum in terms of excitability within the nervous system, where the nervous system gets so excited that we end up having a seizure or a fit. Well, chronic pain is sort of somewhere along that spectrum. Like chronic pain is involving, you know, some sensitization within that system. And one of the things again, that sort of drew my attention right back at the start was one of the, you know, a few of the common drugs that we use to manage chronic pain are also anti-epileptic and anti-seizure drugs. And at the time I thought, well, that's sort of weird. Why would we be using those for chronic pain? Because what they're targeting is that sensitivity within the nervous system. Now prior to medications being brought in to manage epilepsy, it was managed with a ketogenic diet and you can quite effectively manage seizures using a keto diet and even now if you've got refractory epilepsy where there's no, the medications that are available don't seem to manage the seizures. then they put on a ketogenic diet and often get really good results in doing that. So we've known for a long time that playing around with ketones does something to modulate sensitivity within the nervous system. And so all of those sort of mechanisms, I guess, are probably involved in pain management. We can't really, I guess, really say exactly what it is because there's lots of different mechanisms in this complex system. We did a big review looking at all the animal and pre-clinical studies to try and figure out all the different mechanisms involved. When you look at it, there was about 170 different studies looking at what ketones were doing in the system and there's about 14 different proposed mechanisms and there's even been some more mechanisms proposed since we wrote that paper. So there's lots of things that might be involved. in that process of the pain outcomes. So we don't really know, but something seems to work when we put people on it on a ketogenic diet. Definitely, it seems to be helping a whole bunch of different elements coming in and helping the situation in a whole bunch of different directions. You've got the, like you say, the role of glucose, which is essentially sugar, just like those spikes sort of stimulate a bit of inflammation, which contributes to nerve. excitability or that sensitized state, which we talk about a lot in chronic pain. But then also you're saying the, the ketones have a responsibility to, to block inflammation or like have an anti-inflammatory process. So it's kind of like a double whammy effect. Interesting. And so you dive into the research, you say, okay, there might be a link here. Um, there's not a lot of research done on it. Um, And so you take on the responsibility of, you know, conducting your own studies and trying to find some answers. So you've done your own controlled trial. Do you mind talking about that and what ideas you had and the methods that you used? Yeah, sure. So we wanted this trial to, I guess, well, to avoid some of the criticism that's often you know, gauged against these sort of dietary trials. Often they'll... whatever the intervention is that's being looked at, they'll compare it to just the standard diet, so just a Western diet that's full of rubbish and all the rest of it. And so when you're talking about a dietary intervention like that, it's likely that any intervention is going to improve because the diet was so bad in the first place that you're comparing it to. So what we decided to do instead was a run-in diet. So everybody that went into the trial, they did a three week run-in period to begin with. And in that three weeks, all we did was clean up the quality of the diet, because that's something else that's important that we probably haven't spoken about yet. But the fact that diets that have got a lot of ultra-processed foods and things in them, there's a lot of molecules, I guess, within ultra-processed food that are particularly aggravating to the nervous system as well. So what we wanted to do was sort of just, you know, start with a level playing field so that everybody had at least cleaned up their diet. And to do that, we use a thing called the Nova classification, which just is a system of looking at how processed a food is. And so we were just getting everybody to pull out the category four, which is the red category, which is just all your, basically all your fun stuff. So all of your, you know, your chips and your drinks and your chocolates and lollies and cakes, all the things in the middle of Woolworths essentially. And so they were pulling all of those out of their diet to begin with. And then at the three week mark, we randomised people to either keep doing that diet or to continue but then actually reduce the carbohydrate level as well to do a ketogenic diet. And they then continued for another nine weeks doing that diet. So it was a 12 week trial in total. And I think the results were important in that it wasn't just the keto diet that had a good pain outcome. just pulling the processed food out of the diets also had a significant pain outcome. So you know normally when we're helping people with pain management I don't usually just throw them straight into a keto diet to begin with. Like the starting point is really pulling out the ultra processed food. And there's a few reasons I think why the ultra processed food has probably got a lot to do with improving pain outcomes as well. If we think about not only the fact that a lot of the food contains molecules that are damaged or oxidised, and so if you're taking in that sort of food, then you have to have antioxidants to mop that mess up, essentially. So we either make our own antioxidants or come in with the foods that we eat. and they have to mop up that oxidative stress because if that doesn't happen, then that increases the inflammatory loading as well. So by default, if you're pulling out that stuff, that's helping to manage inflammatory loading potentially as well. And I think the other part of that story is possibly also looking at the role of vegetable oils within this diet. So this is probably a bit controversial, but. A lot of the vegetable oils that are used, so we're talking about canola oil and soybean oil and those sorts of ones, they're quite highly processed oils that are already damaged before you ingest them. And most of the ultra processed food is made with those oils. Now again from a pain management perspective, the problem is that those oils, so they're all polyunsaturated fats. which are sort of, if we're sort of just talking broadly, broken down into Omega-3s and Omega-6s. So I'm sure a lot of your listeners would have heard of Omega-3s and Omega-6s before. And the reason why that's important is that the Omega-3s, they are the building blocks for all of the anti-inflammatory molecules and the Omega-6s are the building blocks for all of the inflammatory molecules. So our immune system sort of needs about an even balance of both of those. to maintain good levels of inflammation and manage all that sort of stuff correctly. So if we look at a standard Western diet, we tend to have sort of very few omega-3s coming in and then all the ultra processed food, which is all omega-6, we have tons of that. So we've got a really, a large disparity between the amount of inflammatory precursors that are coming in and the anti-inflammatory ones that we've got going. And there's a couple of studies actually that came into my inbox just last week, Um, just simply the oxidized omega sixes that are going in will sensitize a nociceptor. So just those damaged oils in and of themselves look potentially like they've got something to do with raising up the nervous system a little bit. So if you've got a pain problem and you're having a lot of ultra processed food, then something like that part of the diet that you're taking can also add to the pain problem that you've got. Um, so. Can I ask with this particular study? Um, How many people were involved in like what was the inclusion criteria for them to be involved in this pain study? Yep, so they just had to have musculoskeletal pain. So it was only a pilot study. We couldn't do a big trial. Obviously, when you're doing a PhD, and nobody's funding you, you can't do very, very big numbers. So I think there's about 27 or something we started with and end up with about 24 after there was a couple of dropouts. So yes, it wasn't huge numbers in the study. But I guess it was a pilot to sort of show what potentially could happen so that we could then hopefully somewhere down the track, find some funding, maybe somewhere to run a bigger trial of it. All right, and you said that everyone in the study, because they all started with eating clean, and then three weeks later, you divvied them up to some went to a low carb sort of keto looking diet, and the others stayed at kind of that healthy clean eating. And they all seem to improve. in terms of their pain levels. What were the differences between the groups? Okay, so both groups did get a significant pain improvement. If you're looking at the numbers, the keto group probably got a bit better pain outcome than the others, but both were significant. But in terms of the difference between the two groups, the ketogenic group also improved their inflammatory markers on blood testing. They also improved their... anxiety and depression scores. They also lost a significant amount of weight that the other group didn't do and their quality of life scores improved as well. So there were added benefits to going low carb in terms of pain and other associated outcomes. So I guess clinically how we sort of apply that now is saying, okay, well as a starting point, let's just pull ultra processed foods out. But if I can get people to walk along that with me a little bit and you know, they're entertaining the idea of doing some sort of dietary change, then we say, okay, well now let's actually have a look at the carbohydrates that we're taking in as well. Let's try and remove, you know, some of the carbohydrates out of that as well. By default, when you pull the ultra processed foods out, you do reduce your carbohydrate intake. So we saw that even in just the in just the clean eating group, their carbohydrate level did come down quite a bit. It wasn't down to a low carbohydrate level. So. I think, I can't remember the numbers off the top of my head, but so they went from like an average of like 300 grams of carbohydrate down to you know 150 or 180 or something like that. So it was still a reasonable reduction in carbohydrates just because they're pulling the junk food out of their diet, but it wasn't down to a level that you were considered to be. a low carbohydrate diet. So some of the improvement that they got might have been just because they did pull down their carbohydrate level a little bit as well too. So there's a few sort of moving variables in that for both groups to make it a little bit difficult to say exactly what it was and I guess that's what... you know, when we stand back and look at the bigger picture, that's why we're sort of saying, well, it's probably a mixture of all of those things, you know, it's probably had something to do with the ketones, it's got something to do with reduced glucose levels, probably got something to do with a bit of weight loss in there as well. And probably got a lot to do with improved, you know, psych perspective as well. There's a few things that are happening in that in that study. Yeah. And said they were included if they had any kind of musculoskeletal condition. Was there a limit or? a certain criteria of how long they had to have pain for before involved in the study? Yeah, so it had to be longer, obviously, than three months is the general classification for chronic pain. But the people that we had in there were much longer than that. Again, I can't remember off the top of my head what the average was, but most people had their pain for over a year or more when we saw them. So they were longer term pain patients. And I know with the studies in general, we need to be careful with like a one-off cases and one-off examples, but are there any particular ones that, you know, were surprising to you in terms of the effects they had based on their original presentation, what they ended up with at the end of the study? Yeah, yeah, that's the interesting thing, you know, when you look at individuals, you know, there were some quite remarkable stories compared to when you just looked at the average of what happened to everybody overall. You know, I remember we had one lady who had... chronic plantar fasciitis and she'd had that for, so I looked it up beforehand to be able to tell you, she'd had plantar fasciitis for between two and three years, she'd said, and when we tested her or took her pain scores at the start of the trial, her pain was seven out of 10 with this chronic plantar fasciitis and she got randomized obviously to the ketogenic grip and by I think it was about a week. five or six of the trial, she was down to zero out of 10. Wow. With the plantar fasciitis and at three months follow up, she was still zero out of 10. So that's somebody who's, you know, and she'd been and had orthotics made and she'd had treatment and she'd done, you know, just eating anti-inflammatories all the time essentially to try and manage this chronic plantar fasciitis. And so you think, you know, seriously a diet can't make that sort of difference to somebody. But you know, we hear stories like that all the time. So Obviously not everybody had an amazing story like that. We had other people that didn't really get any pain benefit out of it all. I guess, again, I would question a little bit how rigorously some of them did the diet. But we do say quite remarkable stories. And I guess that's sort of what got me interested in this in the first place, because... I've been interested in diet and I was looking in forums and different places talking about just low carbohydrate diets and people were really coming into the space looking at trying to lose weight or manage their diabetes. They were sort of the usual two big ticket items that people were coming in for but there would be all these other stories and anecdotes that would be in there like, yeah, well, I've lost 10 kilos and I feel heaps better and this shoulder pain that I had for nine months, it just seems to have gone away now. And they were the things that were sort of really... making my ears prick up a little bit. So hang on a minute, you know, there seems to be some good pain outcomes happening here too. And we hear that quite a lot now in the space that people will have come into it for other reasons, but then, you know, they get really good pain outcomes as well from it. So, you know, when we're talking about it as a pain management strategy, it's one of those things where I think it needs to be offered to people, you know, usually when people are trying, you know, they're seeing doctors for pain management here, here have this new drug or here you know maybe we should do an injection or maybe we should you know you could have this surgery and there's never any talk about diet and how diet might play out for you know helping people with their pain experience and it needs to be something I think that becomes common place as a normal part of pain management as well because there's no side effects there's no downside to putting somebody on a diet and cleaning up their diet and then maybe losing a little bit of weight and improving their blood pressure those sorts of things as well because I guess that's the other The other thing that we haven't sort of mentioned, you know, when you look at the typical person with a pain problem, a chronic pain problem, it's very rare that they walk in the door and they're the picture of health and the only thing that's wrong with them is this chronic back pain or chronic shoulder pain. They usually have other comorbidities along with that as well and they usually are that they're overweight and they've got other forms of metabolic dysfunction. So whether they've, you know, their blood pressure's up or... whatever it might be. And I think in one of the earlier studies we did having a look at, well, what is it a typical chronic pain patient looking like? There's an average of three comorbidities. And we know that from all the EPOC data, which is, so all of the tertiary pain services in Australia and New Zealand keep all of their data and put it together that you can have a look at. And so the average person with chronic pain has three metabolic comorbidities as well. So why wouldn't you put people on a diet? If this is your favourite podcast and you want to have inner circle access and a VIP podcast experience, then join our podcast Patreon tribe. 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I found an interesting connection when working with runners and I'd see people with plantar fasciitis for five years and, you know, high hamstring tendinopathies for several years. And, um, I found it a really interesting pattern with those who developed chronic pain and didn't really respond well to a sort of like your traditional rehab, the likelihood of them also having some sort of depression, anxiety. disorders and the link between those two I found just in my, you know, my caseload, particularly profound, like the link between that is quite crazy and learning about pain and I guess their default state would be catastrophizing, would be like, you know, over-amplifying some scenarios and sort of dwelling on thoughts and that whole overloading the psychological system and Like you said when someone does a a particular study lift, if they go through this keto trial, like you did, um, they're probably settling down a lot of their anxieties as well. They're probably feeling like, you know, maybe this is the answer feeling taken care of feeling like they're, you know, got the right support or, you know, maybe, um, a bit hopeful about the outcomes and psychologically that can wind things down as well. Um, and would essentially like theoretically, I guess, boost the effectiveness of it all. When we're thinking about how much control people feel like they have when they're in a chronic pain problem, it's almost like they've sort of given up. They're throwing their hands in the air and saying, I've tried everything, I've done everything and nothing makes this pain any better. Whereas if you can say, actually, here's a really good reason why diet might help. And it's something that they can actually have a bit of control over too. So you're giving them back a little bit of control and self-efficacy and all those sorts of things as well. And so that helps to, if we're talking about this like a set of scales. of how much evidence have we got of danger and how much evidence have we got of safety. Well, then you're building in some safety side to that set of scales and starting to maybe hopefully change the answer that the brain's coming up with or the prediction that the brain's making about how much danger am I actually in. So yeah, you're absolutely right. How about for non-chronic conditions? Like if someone has plantar fasciitis, but they've only had it for four weeks rather than three months, do you think... they can think about diets, do you think that it might have an impact on them? That could still be sort of sitting at a just subclinical level in terms of their inflammation that just sort of you know. flares up and down every now and again. I know myself, when I was younger and I'm trying to run, I used to get plantar fasciitis and Achilles tendonitis all the time. And I'd tape it and take any inflammatory and do all these things. And I'm sure now reflecting back on it, I probably had a level of inflammation that was sort of sitting up a bit higher than it should be because of all the rubbish that I was eating. And every now and then you just do something else that would just add a bit too much load to that structure and then we'd end up with a clinical problem. Again, we would settle back down again in a little bit. I certainly think that diet is one of those levers that you can pull in a management, overall management strategy that gets totally, totally overlooked. But yeah, definitely. Okay. And if someone has a look at their diet and they're thinking, okay, maybe suboptimal and I do have like a grumbling sort of knee pain. What are some big changes they can make or some practical changes? You mentioned, okay, most people are familiar with vegetable oil, sort of reducing those. You mentioned ultra processed food. roots. Can you use some examples of what some ultra processed foods might look like and, uh, what we might substitute them for what, what some big changes might look like. Yeah. So ultra processed food, usually the way that I get people to think about this is to look at the ingredient list on the, you know, the packet of whatever it is. And if that thing is made up of five or six ingredients and you know what each one of those ingredients are, and you could walk around Woolies and pull them off the shelf, then that's fine. But if it's got numbers and letters and things that you have no idea what the are in that ingredient list that's by default an ultra processed food and you want to try and get rid of it. And so sometimes depending on what the item is, it can just be a matter of comparing different brands and you might find some brands have got a lot less additives and things in them so that's a better choice to make. But you can also I guess think about it. You know something like a coffee for example. So if you were going to go and buy, I don't know, one of those lovely, you know Frosted latte things from Maccas or something like that. That's obviously going to be riddled with all sorts of you know stuff in there That's going to be a very ultra processed product Whereas if you were to go to a cafe and have a cappuccino that's just made on you know Normal full cream milk and that just you know, brewed the coffee straight from grinding the beans Well, you'd call that an you know, a minimally processed things added to it. So you can make good choices. Something like bread is another good example. So all of the bread that you were going to buy in Woolies is going to be ultra processed and it will include your vegetable oils in there, but there'll be all sorts of other preservatives and emulsifiers and things in there as well. So really if you were baking your bread at home in a bread maker, well that'd be a much better option or something like getting a proper sourdough from been you know made with the you know fermented process and all the rest of it and all I've done is just add you know flour and salt and water or whatever to the bread. Well that's a much better option than potentially and it's already started to break down some of the glucose as well through the fermenting process. That would be a better option than having the you know the Wonder White from Woolies. So I guess it's just starting to think a little bit more about you know, what can I actually make myself at home or buy? that's less processed. So, you know, even down to, you know, if you were gonna be making, I don't know, something using a jar of Dolmios or one of those sort of, you know, simmer sauce things. Well, obviously that's got a lot of processed stuff in it where you could just chuck the can of tomatoes and some herbs and things in yourself to the meat that you're making and that would be a much better option. So yes, it probably takes a little bit more forethought and it probably takes a little bit more planning and you have to cook a little bit more maybe for yourself, but it's quite doable to reduce the amount of processed food that you're taking. I guess if we're talking to athletes and runners and stuff like that, I'd probably challenge to look at some of the, you know, the things that they're eating in terms of bars and, you know, other gels and process things and stuff. There's quite a lot of those convenience things that are very processed and you really don't know what you're taking in when you're eating a lot of those. Yeah, I think a lot of times overhauling your diet can seem quite overwhelming, but I guess, steps at a time, particularly if you're just wanting to try it out as a bit of an experiment. And even just start with breakfast, just fix your breakfasts. Start there because breakfast is often one of the more processed things. People are having cereal and things like that. And obviously cereals are all ultra processed, but you know, scramble yourself up some eggs and chuck some veggies in there or have some salmon or like you can come up with some other things to have for breakfast. And that's probably a really good place to start. Just focus on that to begin with and see how you go. I'd even say like, even before you change anything, maybe don't change anything, but just have a look at those labels and see how many ingredients are in the things that you're usually eating, maybe just start with a bit of insight and then see what changes you might want to make from there and what you might want to substitute out. And if someone wants to make these changes, let's just say they have chronic pain right eating healthier, getting rid of those ultra processed stuff. Is there a period of time that they should try to see how much of an involvement diet has in their role? Like we say, you know, pain's, you know, so complex, multifactorial, that they want to just do a little experiment to see how much of a role this diet thing plays. Should they wait a week? Should they wait a month? Like, how long should we continue this process before seeing how much of an effect it does have? Yeah, and that's a good question. I think really if you're going to make any sort of dietary change, you've got to do it for at least a month or six weeks to be able to really say whether it's made a difference or not and be consistent over that time period. Because something like changing carbohydrate level, if you're really good for a couple of days and they have a couple of bad days and a few good days and a few bad days, will really, like the time that it then takes your system to get back into ketosis after having a bender of a day will be days again if you're not that adapted. So you're really not giving yourself the opportunity to see whether it's making any difference or not. So whatever change that you're going to make, whether it's only a small change or a bigger change, you need to decide what you're going to do and be consistent for long enough to be able to actually make a... judgment call and whether it's made any difference or not. And I would normally tell people in my practice, like, you've got to do it for at least six weeks properly to be able to, you know, say whether it has or it hasn't helped you. When I was talking to Peter Bruckner about the low carb diet, and pretty much doing that for athletes, and he mentioned the role of inflammation that those sort of things. A lot of people loved the interview, and some reached out saying, or like using I guess certain circumstances they said like a female athlete who's still running and like wanting to achieve optimal performance, like a low carb diet might not be the best option for them. And they have, you know, experts like Stacey Sims talking that female athletes should be having a high carb diet. When it comes to pain, I guess with unique circumstances if, if someone is still running, they're still like a an athlete, but just managing a grumbling knee issue. And we're sort of suggesting maybe a keto diet might help their inflammatory markers, but they still need to perform. Is there some middle ground or do you have any particular recommendations for them? Yeah, I guess if we're talking about athletes, then you've got to probably think around it a little bit differently because there is a period of time that requires you to adapt if you're going to change what your fuel source is. So and that can take, you know, if you're just talking about the average Joe Blow, we'll give them a few weeks and they're probably, you know, they can adapt along. But if you're looking at particularly like higher elite level athletes and things like that, then it's probably going to take them several months to actually fully adapt. change their diet so radically. So yeah, I certainly wouldn't recommend, you know, doing something like that if they're in the middle of their, you know, performance season or something like that, because their performance will probably tank initially because you're having to change the metabolic machinery around from something that's a glucose burner over to something that can then adapt and use fat instead. And so the, you know, there's a bit of research out there looking at ketogenic diets and athletes and this is not my area of expertise at all. But in the, in the review that we did when we were looking at what sort of human research was out there to inform us about inflammatory markers and any other sorts of neurological outcomes. When I did that review I also pulled out all of the research that reported on a low carbohydrate diet, so we're talking under 130 grams of carbohydrates per day and longer than two weeks. 50 or 51 sports trials in there as well. So that would be the literature that you would probably want to look at to inform, you know... you know, how long it takes to adapt and what sort of, you know, training changes would need to happen with doing that. There is a body of other research that sits in there as well, but it's all sort of less than, you know, two weeks, some of those trials. And so they are really highly criticised from the low carb side of things saying, well, you know, you can't expect an athlete to have adapted in a two week period to being back, you know, having good performance outcomes. So certainly having a look at that, that research would be starting point and if you have a look at that and I can send you the link for that paper but in the extra bits of the paper, the supplementary files, I've listed out all those 50 studies there if you wanted to go and look them up. But I think you know there's a few sort of eminent researchers in the space so probably Jeff Follock and Steve Finney are the two researchers that are researching within the elite athlete performance area with low ketogenic diets. So looking at their work would sort of probably inform people's decisions a little bit more if they were, you know, higher level athletes. And I guess there's reassurance to know that, I guess if you are a female athlete, that's, I guess maybe their beliefs that they want to keep carbs in, they think they thrive off carbs. extracting from like stories from your particular research, people get a lot better if they just have clean eating as well. If so, if they do have pain, and they're looking to try and manage it with diet, getting rid of the ultra processed foods and maybe keeping carbs the same might have at least some effect as shown in your study. It would be worth trying. And the other thing is that they might not need to get the carbohydrate down to that level of, and particularly if you're talking about athletes, you know, if you're, if you're If they're doing a lot of training and things like that, they might still be able to have 150 or even 200 grams of carbohydrate in a day, but because they're training so hard, they're still intimately getting in and out of ketosis compared to if they're really carb loading, having 300 or 400 grams of carbohydrate a day. You can still reduce your carbohydrate a certain amount and still have plenty of carbohydrate coming in, but I would say you want that to be whole food carbohydrate. You don't want it to be processed carbohydrate. And there's other ways that you can play around with it as well. We know if you eat your carbohydrate at the start of the meal versus at the end of the meal, produces a different blood glucose response. So even doing something as simple as making sure you prioritize your protein first, eat your protein and any fats that are going along with that, and then fill in with a bit of whole food carbohydrate at the end, is probably going to have a different blood glucose response to if you had a whole big bowl of carbohydrate at the start, and then just chuck some protein at the end of it. So even things like that can make a difference. Well said, yeah. Is there any other final takeaways or anything that we may not have discussed that you think might be relevant to today's topic? Not that I can think of. Like, you know, there's quite a lot of people out in the space talking now about performance stuff so there's some good podcasters to listen to. If they look up, you know, athletic performance and low carbohydrate diets, I'm sure they'll find lots of people to listen to. And even in the female athlete sphere, it's probably quite contentious how much carbohydrate you really need. Sometimes we sort of, we've been sort of, I guess, conditioned to believe that, you know, carb... know that we have to have carbohydrates but there's no such thing as an essential carbohydrate. There's essential fats and essential proteins but not essential carbohydrate because our bodies can make that itself as required. So there's some controversy in there about you know even as female athletes or females whether we do actually need more carbohydrate or not for managing you know menstrual cycles and things like that so I think it's probably the thing you sort of got to play around a little bit with yourself as an N equals see what happens and you know I guess when we're thinking about runners as well there's a lot I mean historically we've always talked about you know carb loading is being something that you want to do before performances and things like that but again if you think what you're doing when you're carb loading you know what your blood sugar is doing during that you know low that amount of carbohydrate that you're taking could also be having detrimental effects in terms of your inflammatory loading and also you know and ligaments and things like that. So you know perhaps not as big a carb loading might be a bit of a better strategy and there's a I don't know if you've heard of Professor Tim Noakes he was a South African professor who he wrote one of the textbooks I think for distance running and things like that and he was so he was a big advocate of carb loading and all the rest of it and even though he was an athlete himself and did lots of marathon running he ended up with diabetes scratch your head thinking, okay, he's done all this exercise, how would he end up with diabetes? But the amount of carb loading he was done still meant that metabolically he wasn't well and ended up a diabetic. And so he famously ripped the carb loading chapter out of his textbook saying, look, this is not exactly, this is not really right anymore. We need to actually look at the metabolic health of people as well, not just whether they can perform and run when they need to. So I guess thinking about you know, the amount of carbohydrate that you're taking in as an athlete is probably something that's worthwhile thinking about. And I suppose, you know, if somebody was really interested in monitoring that and seeing what sort of blood glucose responses they get, you can always wear a continuous glucose monitor for a two-week trial period and have a look in real time exactly what's happening with your glucose as you're training and as you're eating various things that you eat to see what sort of blood sugar spiking you're getting. And that would probably really inform what you eat and how you train as well. well. A lot of athletes are very data driven. So that might interest a few. I'm sure they would love wearing a glucose monitor. Have you seen them? So they're the, you know, the like little just a little disc that you wear on the back of your arm and your iPhone reads it. So you just go beep and you're you can read every time you eat something you can just tell and it gives just gives you a constant 24 hour. you know, print out of exactly what your blood sugar is doing at any given time. So you can have a look to see, well, you know, is that that, you know, breakfast that I had, did it just give me a bit of a spike and a settle down? Or have I had a huge spike or was it up for ages afterwards? So that's really telling you what glucose loading is going on with you, you know, with respect to your diet. Yeah, excellent. Um, what are some social media channels or, um, things that places people can go to learn more about you and learn more about, I guess, pain science? and the role of diet. Do you have any social media things that people can be drawn to? I'm not a big social media person really. I am on Facebook and Instagram and Twitter and things, but I really don't put very much up on there because it's just not really my gig. If people wanted to talk to me about something or contact me, they can always contact me through my work website, which is step.com.au. So step with two P's, which just stands for solutions, tools, and education for persistent pain. So they can always shoot me an email there if they had a particular question they wanted to ask me. Yeah. While we're on that, do you mind maybe just briefly explaining what that STEP program is for people who might be interested? Yeah, so that's a specific chronic pain management program that was developed by myself and my work colleague who's a psychologist because we really, I guess, realised that to manage chronic pain it's not just about the physical and the structure, it's also about the pain science education and it's also about the psychological health of the person. So we sort of work together in this program and people can either come and see us as private clients or we do a lot, most of what we do is work as comp and we see people with we do a bit of an education program for sort of a few weeks initially, and then we sort of have various, well, various physio sort of things, and she has various psychological sort of treatment strategies that we then sort of implement with people in an ongoing way to try and help them learn about their sensitized nervous system and what they did to get that way and what they can do to, you know, potentially change things and get it to move back into a less sensitive state. All right, excellent. Well, usually on the topic of nutrition, I interview a lot of people nutritionists and dietitians and stuff and it seems like after... that conversation, there seems to be more questions and answers, you know, you're trying to answer something, it just leads to more questions, but particularly on the pain side of diet and like a low carb diet, you seem to knock these all out of the park and explain it very precisely and exactly what the role is with diet and pain. And so thanks for coming on and sharing all this and well done for you in your previous research that you've done. Is there anything next on the cards? Anything that any other research or things that you might be Yeah, actually we've just put in a big NHMRC grant at the Uni of Sydney that I still do some work with looking at doing a ketogenic diet for narcolepsy. So hopefully we're going to be involved in that project. So we were talking about epilepsy before, narcolepsy is sort of like the opposite end of the spectrum. Instead of your nervous system getting so sensitized that you have a fear that it gets so depressed that they fall to sleep, essentially. So again, there's something about ketones. oldie locks level in the middle, so whether that's getting too high or too low, there's something about ketones that potentially help to improve those outcomes and improve their sleepiness and things like that. So we've got our fingers crossed that we'll get that grant and then I'll be involved in running that trial as well. But other than that, I'm just, yeah, just doing private work with the STEP program and I've got a few other little projects going at the uni, helping some students with various things as well. So yeah. Very cool. Well, I guess. more things to for the runners to, I guess, analyze, self-reflect on their particular diets and the pains they've had in the past and their recoveries and would help a lot of people and help them train smarter. So thanks very much for coming on. Thanks for all the work you've done in the past and thanks for coming on to the podcast. No worries, my pleasure. And that concludes another Run Smarter lesson. I hope you walk away from this episode feeling empowered and proud to be a Run of runners who recognise the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated active role in their rehab, who are looking for evidence-based long-term solutions and will not accept problematic quick fixes, and last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode. and helping you on your run smarter path.