9. Jenifer Tharani, MS: The Role of Nutrition in Chronic Pain and Autoimmunity

Hello everyone, I'm Dr. Darsha Shah, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined, a podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Before we get into the show, here's a quick message from our sponsor MR Insurance, a small business that helps physicians with their disability insurance needs. Michael L. Relos is a CFP professional and insurance agent committed to helping physicians nationwide with their term life and disability insurance needs. He provides an objective, transparent, and education-focused process that aims to help physicians make prudent decisions and avoid over complicating things. He exclusively offers own occupation and disability insurance policies for residents, fellows, and attending physicians. We really like Michael, and know he's got your best interest at heart when it comes to disability insurance. We know he'd be happy to help you with whatever your needs are. You can find Michael at Drpodcastnetwork.com, 4-slash-MR Insurance, or contact him at 800-817-4522. Alright everybody, today our guest is Jennifer Tarani, and she has completed her masters in human nutrition from Texas State University. She also has training in diatetics from Emory University in Atlanta. She's a member of the College of Dietitians of Ontario and registered with the commission of diatetic registration. Jennifer's mantra is, give a man a fish and you feed him for a day. Teach a man to fish, and you feed him for a lifetime. And so she has expertise in giving patients a nutritional toolbox to help manage their chronic pain, their health conditions, and to just live a healthy lifestyle. In this episode, some of the things that we go through, one, we talk about the role of elimination diets. We also get into what it really means to be dairy and gluten free, and is it advantageous to do those things, especially more and more as we're seeing companies kind of market their food that way. We get into what leaky gut means, and how that can affect the immune system, and last but not least, we talk about the other ways that diet can play a role in chronic pain as well as anti-inflammation. Okay everyone, let's get straight to the show. All right, hello everyone. Today we have a special guest, Jennifer. How are you today? I'm doing well, thank you. Yeah, thanks so much for coming on here. We're super excited about this topic, chronic pain nutrition. So let's get into it, can you tell our listeners about yourself, your journey, what really got you into not only just nutrition, but a specialized niche in chronic pain? Right, so I actually got into nutrition after my trip to India. So I have a bachelor's in food science, and I learned all about food and ingredients and product development on all of that, but I went to India and I got an opportunity to design like a program for a parent toddler nutrition program, and it was just out of a whim, they found me and it was in our community and I was like, sure, I'll do it. And I did some research and I put together like a quick program, but I found like because of my extrovert personality, I was like, this is amazing, I'm just, I just loved like teaching them about nutrition and all of that. So then I went back to school and got my master's in nutrition and actually became a registered dietitian. So that being said, I started off with weight loss, seeing weight loss patients more so because I found in my diet, I think internship, I really enjoyed bariatric rotation, bariatric surgery rotation, and it's more about the pre and post surgery nutrition, but a lot of it is like habits and all of that. So I did that, but it just didn't fill my cup. And then my master's was actually an anti-inflammatory nutrition. And after moving to Toronto, Canada, I got in touch with a few chiropractors and physiotherapists. I actually worked in a chiropractor clinic. It was a more multidisciplinary clinic where there were doctors, physiotherapists and chiropractors. And I found no one was talking about nutrition, you know, and I as a dietitian over there was also doing mainly weight loss and other medical nutrition therapies. And in having conversations with other professionals is when I realized, I started connecting the dots and actually my mother has chronic pain. And this started after a minor injury that she had and it was an address properly at the time. I went to acupuncture and doctors and this and that, but that acute inflammation became chronic and then she started having all these other issues. So I was like, okay, as a child, I didn't understand any of these things, right? My mom had to be like, no, I can't go to movies with you guys because I can't sit for three hours. And it was very disappointing as a child, as a kid, I would just like throw tantrums and I would just be like, dearly eyed and then my mom had to pop pills, like take opioid or pain medicine. And then, you know, she would go with us and a lot of times same thing in the kitchen. And I just didn't understand and she would say no to going to social events like weddings. If you know anything about South Asian weddings, they're like four or five, 10 days long and my mom couldn't keep up with any of that. So then I started connecting the dots. Actually, the last two years, I've done more and more research in chronic pain nutrition and all of that. And I was like, I have the expertise. I have the empathy because I've seen my mom struggle and I know it's invisible and not a lot of people know about it. And there's a lot of misconceptions and misinformation out there. So that's what got me into, you know, focusing on this niche where I help warriors with chronic pain, autoimmune and rheumatic conditions with their nutrition. So that was a very long answer, but that is like my journey to getting to this point where I feel like my cup is full now. I love that Jennifer. I mean, you know, yeah, it's a long answer, but that's your story, right? I mean, and that's really important. And, you know, what I find fascinating about this, because chronic pain nutrition is not a very sexy topic, right? Most people who are in the nutrition workspace are in there because they're working with people for physique purposes, weight loss, and that's the common place to be. But I find that people who are kind of really passionate because either they've had some personal injury had their own personal struggles with pain or have had a loved one, such as you have with your mother, who've kind of gone through that, use the word empathy, right? I mean, that's really important to have in this space, especially because pain is such a subjective thing. You can't see it. Yeah. You can't identify it, right? You can see how your mom made sacrifices and how that affected your quality of life and her quality of life, because I'm sure when you were throwing those temper tantrums, she was probably also hurting inside, right, emotionally, because she could be there for her daughter. So, so they, I mean, I really love that story, and I love that that you use the word warrior is I'm going to ask you more why that term, but I think it's worth maybe taking a step back and describing the difference between a nutritionist and a dietitian, because I think sometimes people use them interchangeably and I don't think they're the same thing. So, what's the difference? Thank you so much for asking this question. I love answering it because as a registered dietitian, it's similar to doctor, but in nutrition, right? I had to have, I had, I have a bachelor's degree, two master's degree, and I had to take a, I had to go through a dietetic internship, which was 12 hours of supervised practice in cardiology, oncology, like pediatric nutrition, all of the different nutrition arenas, and then had to sit for an exam, pass the exam, and then become a registered dietitian, right? So, and then I have to keep renewing my license every year. I'm regulated by a regulatory body, and then I also have to keep up with my continuing education units. That being said, previously, if you had a bachelor's in nutrition, you could apply for an internship and you would be eligible for an internship, however, starting 2024, all the nutrition students are going to have to have a master's degree. So, we are just leveling up, and then be able to become eligible to apply for a dietetic internship and then become registered and licensed. Nutritionists, so registered dietitians can call themselves nutritionists, however nutritionists cannot call them registered dietitian, it's a protected title, but, so anybody, you know, anybody, let's say someone had autoimmune illness, right? They helped themselves with food and nutrition, they are now in remission, and then they went and did like an autoimmune protocol coaching, right? Nutrition coaching, they can call themselves nutritionists, or anybody can call themselves nutritionists, but not registered dietitian, yeah. Gotcha, you know, it really amazes me when you were talking about your masters, how niche it can get, you know, I wish, I really wish there was something like that in medicine where you could even get a further degree, and I mean things are slowly coming out, but a lot of it's really not board certified and things like that, but that really does amaze me. And that was a great explanation, by the way, I honestly did not know that. So let's get into the weirdo, yeah, it's called a fellowship, dude, you can get a different degree. I mean, you can do a fellowship, but I mean in terms of, I'm just, I'm not, I'm not studying well. I'm not, I know I'm a slowly intern, but just picking on my interns here. Yeah, I do have what I need to be in too. Yeah, but they're always amazing, you know? Yeah, cool. Okay, so let's get into the weeds a little bit here, talking about pain and inflammation. So, you know, we're starting to hear words like inflammation, where we're taking inflammation and saying, hey, this is what causes the aging process, and we can also look at pain from an injury standpoint, where if somebody rolls their ankle, you start to see it swell up, that's that inflammation. So does pain always coexist with inflammation when you're dealing with your patients? Are you always seeing the two together or can they be separated? Yeah. So, if you guys don't mind explaining what acute inflammation is and what chronic inflammation is, then I can go ahead and respond to that question. You want to take a stab at that? Sorry. So, it was what chronic pain is and what chronic inflammation? What is acute inflammation and what is chronic inflammation versus chronic? So as a DO, this is kind of what we learned with what are our tortures, right? So acute pain would be more of the, I guess objectively, you would be able to see it, I would say. Yeah. It's a little more swollen, there's a little more heat to it. The texture is it as ropey, if I could use some OMM words here, versus chronic or things where that swelling might not be there, but still that inflammation process is going on chronically to the point where you might even be dulled from the pain. You might not even feel at that point, but structures inside your body, whether it's the muscle, connective tissue, etc., are still debilitated for lack of a better word. Yeah. And I'll add on to that. I mean, it really also depends on the type of injury that you have, right? That's causing the pain, right? For instance, a gallbladder elaceration or acute colicistitis is going to be a slightly different injury than an ankle sprain where you have a ligamentis injury. But essentially the inflammatory process is going to be somewhat similar in the sense that you're going to have a massive, you know, a cytokine response, you're going to have macrophages. A lot of them are going to be upregulated to go and promote that healing response. One of the things that we love in our field of musculoskeletal medicine, and I don't know if we talked about this before, but I'm going into sports medicine is, you know, orthobiologics is a big one. You might have heard regenerative medicine as a term and platelet-rich plasma. And we know that platelets also go to the site of inflammation to try to stop the clotting and get the whole cascade going. So that's good. You want that. And after, like, for instance, going back to muscle, you want a acute inflammation. That's a body's way. That's natural. Systemically, if you have an infection, you'll have an inflammatory response. Like, the fever is an inflammatory response. You want that. Yeah. Chronically, it's like low-level, that's not good. That's, I think, ultimately what we're talking about. In autoimmune conditions, and correct me if I'm wrong, it's typically, it's not always inflammatory, right? It's more flares, like rheumatoid arthritis. Is that correct? No. So actually, I'm glad you asked. So this chronic inflammation, so a lot of patients will have chronic pain, right? So it lets just kind of unpack this a little bit. So if someone has a herniated disc or an injury from working out in the gym, they never paid attention to it. And that acute inflammation then became chronic because then on top of all of that, they had like sleep issues, then sleep well or stress, all of those things that made it chronic inflammation. And with autoimmune conditions, it's basically your body attacking itself without any invaders. So there's literally, like, nothing happening is just your body thinking that there are invaders in the body that it needs to get rid of and it just attacks itself in autoimmune and rheumatic conditions. However, in pain, it's the transition from acute to chronic inflammation that wasn't addressed in the first place. And a lot of time trauma, right, like trauma can be a huge inflammation, like your body will respond with inflammation to a trauma, traumatic event. And then if that's not addressed properly, then that will also become chronic, concussion, like accidents. That's another one I work with, both concussion patients who are on depression medications and, you know, have neuroinflammation, right? So we're talking about, we kind of work through that with them, yeah. Yeah, we see a lot of people in our field because we do a electromagnetic brain injury. Yeah, I mean, concussion is especially the post-concussive syndrome when you have these prolonged symptoms. I mean, that can be, it's a constellation, right? You have somatic symptoms, you've got neurocognitive issues, you've got sleep and all these. And, you know, we recently had a psychologist and we talked about the correlation between pain and sleep and how that can be disruptive. And so, you know, when Darshan and I, we kind of look at this, we have like these pillars, the foundational pillars of what we consider medicine, hence the name of the show. And we define it. And, you know, sleep is one of them for sure. Exercise is one of them. We haven't dovetail too much into that. But nutrition is one of the main three pillars and this is what you do. You do chronic pain nutrition. So, you know, my question for you would be, what role does our nutrition, what role does our diet play in helping manage these inflammatory conditions? But before you add to that, I also want to ask you, do you primarily only work with like these autoimmune inflammatory conditions or, and then concussion, of course, or are you seeing just normal chronic back pain and the chronic musculoskeletal pain that might not be necessarily because of fibromyalgia or RA or, or like, lupus or something like that? Yeah. So, I see all of them actually, if they have chronic pain or, yeah, autoimmune or rheumatic conditions or concussion, yeah. Cool. So, I mean, ultimately, you know, what are your thoughts? I know you talked about your journey of, you know, why you were interested in learning about chronic pain and then your role of nutrition, but in terms of one thing that we don't get educated on, well, we don't get educated that much on nutrition to begin with. They can be honest with you. And I think that even pain is such a complex phenomena that we don't truly understand it. And so, we have two complex topics and you're putting them together. So, you know, I think that maybe, because you said you have an intern, so you're obviously educating people, what's your approach? What's your approach to educate maybe your colleagues, your interns, people who are in the field and then maybe even the patients, the lay population who might not have the background to understand these complex mechanisms? Yeah. So, number one, we don't know much, I mean, we do know a lot about anti-inflammatory nutrition and its role in reducing chronic inflammation and those inflammatory markers, right? However, in some patients that I see their inflammatory markers are just within normal limits. They don't even have high inflammatory markers, right? So, it's a very complex, like you said. That being said, like the nutrition does play a role from the angle where we are trying to reduce that chronic inflammation, the burden of chronic inflammation with the nutrition, the medications work better for these patients. And number three, gut. Right? So, gut healing is an extremely important piece of the puzzle, which I work with my clients. So, some of the topics that I cover, I don't know if you want me to go into that right off the bat, like some of the important topics that I like to cover, but like you said, fillers, right? Sleep, nutrition, but for me, my main to begin with is like figuring out and identifying their unique trigger foods if they have any because there are a lot of like elimination diets out there that kind of eliminates everything, right, like all possible triggers under the sun. So, I focus a lot on food and symptom recognition and figuring out what their triggers are. And then I come from the angle of addition of these anti-inflammatory foods versus restriction. I do help my clients with, you know, eliminating the food triggers, again, for the gut healing purpose, and then also teach them about how they can keep their gut microbiome healthy if that makes sense. And no, absolutely, just curious, what specific inflammatory markers do you pay attention to the most? I'm sure it matters and it varies from condition to condition, but are there a baseline that you're always looking at and kind of monitoring? Look at CRP for sure, and then ESR is the other one, and then mostly those two, and then I look at any nutrient deficiencies because nutrient deficiencies can play a huge role as well. Gotcha. So, if I could ask, you know, when you're measuring progression of these patients to see if they're getting better, how do you separate, you know, if they are on medications versus the diet? Is there a way that you can tell one, like the diet is primarily working and that we need to continue with it? Yeah, so in a lot of my clients, the medication dosages are reduced, and that's how kind of I can tell that the diet is working, and also, so when they come to me, they are on some medications that sometimes are not working either, so a lot of times the doctors kind of doing trial and error, trying to figure out which medicine would work for their autoimmune and rheumatic condition, because there are so many. And on top of that, like medication side effects, GI side effects, brain fog, and then muscle stiffness, those are like waking up with stiff joints, ultimash mentioned something about flare ups, so the severity of the flare ups or no flare ups at all. So, you know, all of those are the things that I look at, so labs are one, but the quality of life, if they came to me saying, I want to exercise, but I literally have no spoons to exercise, like I don't, you know, I crash in the evening, so then that is another thing I look at, like, okay, now you're able to exercise, right? You have less brain fog, you have less fatigue, you have more energy, your quality of life has improved, those are some of the most important markers that I focus on. Gotcha. And then, so, I mean, if you want to delve into the topics that you wanted to talk about, we can definitely do that. I think, you know, we can go down any route here with, you know, gut health, to elimination diets, to, you know, different food sensitivities, possibly, ultimash, do you have anything though that you want to add before? Yeah, I think that it's kind of worth separating the different types of pain, right? I know that we kind of touched that length with Patrick recently, Patrick Feinand, who I mentioned before, came on just the mechanisms of pain, but we know that like we have this primary pain where kind of you have no true identifiable cause, right? It's kind of like this non-specific little back pain. And then, these secondary pains are when you have a true cause that are contributing to it, that could be like cancer contributing to pain, rheumatoid arthritis, autoimmune conditions where you know you have something that's contributing to pain. I think it's pretty safe to say that this last year has been very stressful for everybody, right? So, again, as you mentioned, sleep, it's really kind of looking at the individual from all aspects of their life. And we know that pain and mood are mental health go hand in hand. Now, I don't, for the, just purpose of discussion, I don't think it's worth diving too much into mood related stuff, but have you seen in your practice that just the people presenting with new pain or, you know, chronic pain again is basically anything going on for three months? Are you, is your basically volume gone up with people presenting with more? Have you seen, and if so, is it more from that primary, non-specific or is it more of the inflammatory conditions have basically triggered up, if you will? Yeah, not necessarily. Like, I don't have a answer to that question because I see like my full time job is in the chronologist clinic, so I see diabetes, weight loss, thyroid, autoimmune, all of that. So in that, in my clinic, I have seen a lot of people, you know, come to me with things like, oh, I've gained weight and now I have knee pain, right? Things like that. But otherwise, just simply speaking, like, I don't get very many of the clients who have primary or non-specific pain, my most majority of my clients are people who kind of know what's going on and what has led to their pain. So it's like the secondary pain, yeah. That's interesting. Do you see a lot of diabetic neuropathy as well? Mm-hmm. Okay. Yeah. So I think that it would be really good for us to go through kind of a case study, right? We know that, you know, if over a couple of months, as you mentioned, if people gain a lot of weight because of diabetes, that's a very common thing that happens. Maybe somebody's arthritis just flared up because their knee's taking a lot more load now. How would you maybe manage that person or if you recently can think of somebody, obviously, without identifying any person and then diabetic neuropathy, which is more of this neuropathic pain, is your approach a little bit different in how you're approaching that with nutrition, whether it's supplementation, whether it's, you know, eliminate X, Y and Z and try this or just curious to what your approach would be and how it would be difference between the type of pain, if at all. Yeah. So with weight loss, if they come to me, the only problem with nutrition is they don't stick with you for a very long time to really kind of see, you know, what is going on. So it's like you have to pick one or two goals at a time. By the time you kind of have them achieve those goals, they're well on their way, right? That being said, in a patient who has, let's say osteoarthritis, which kind of flared because now they gain 10 pounds over COVID, right? So the idea would be definitely to help them lose the weight through. So my approach is going to be very individualized. It's going to all depend on whether they need more mindful eating approach, more calorie counting approach or more macro nutrient approach, right? So I kind of see what is going to work for them the best. And then sometimes I lead with just, okay, let's start by eating structured meals, right? Because a lot of people, and I know we were going to talk about intermittent fasting, which is basically opposite of grazing. And a lot of people have gone to like grazing situation during COVID because they're so close to kitchen and every time they have bored or stressed, they go to the kitchen and eat something, right? So that would be something that I would put in place first is like, okay, let's take a proper lunch break, let's eat breakfast, lunch break, and then dinner meal. And let's make sure that your meals are really well balanced, right? And once they start getting all those anti-inflammatory nutrients in those meals with gaps in time where they allow their body to digest their food properly versus just constantly grazing and grazing on empty calories, quite often that's what happens. Then after that step is like hydration. Hydration is super important with a lot, which a lot of people don't think about. They're busy, they forget, they don't have a water bottle in front of them, they just don't like water. Good job. I'm guilty of not having one. I meant to have. Yeah, so hydration is extremely important. And then a lot of times people are just kind of drinking soda or carbonated water, which is great, but how much carbonated water are you going to drink in a day, right? So that's next thing. So my approach is very much like habits based approach. I take a very basic approach, sometimes people think, oh, this anti-inflammatory nutrition has to be something like miraculous diet, right? But I'm like, let's just look at the basics. Are you getting your omega-3s? Are you getting your fiber? Are you getting your enough fruits and vegetables, whole grains, beans and lentils throughout the day? And then that's how they get those anti-inflammatories in their meals and snacks. And then I will add any supplements on an as needed basis. So let's say like, you know, they don't have good quality sleep at night and they're complaining that because of pain, they don't have good quality sleep. And then I might go ahead and add magnesium supplement depending on, you know, whether they have any other medical conditions going on, you know? So if the supplement approach has to be very, very, very individualized here. Is your certain brand for magnesium that you like? So as dietitians, you're not supposed to give brands or not associate ourselves with brands, but I can tell you the forms for sure. So if I have, let's say like taking an example of rheumatoid arthritis and fibromyalgia patient who has IBS, okay? So now this girl came to me. She had IBS and her IBS players were triggering her fibromyalgia pain flares, right? So in that situation, and she would, she didn't know what to do and she was having a lot of diarrhea. So in that situation, I wouldn't recommend magnesium citrate because it would just exacerbate her diarrhea. So I would recommend magnesium glycinate, but if someone came to me with chronic constipation because they are on pain meds and fiber is not working, nothing is working, then in that case, I would recommend definitely up there and take a fiber, increase there and take a water and then recommend magnesium citrate in that situation. So that being said, doing like a low FODMAP medical nutrition therapy with them is going to be extremely important, especially if they have irritable bowel syndrome in addition to pain and other autoimmune conditions. Thank you. Super cool, Jennifer. And I love that you said it comes down to habits and lifestyle, right? Because I think that's one of the things we preach on this podcast is that before anything else, it comes down to how you're going to live your life, right? With those daily habits and making sure that's taking care of first before we can move into those super foods and all those crazy kind of biohacks and whatnot. So let's get into that though a little bit, right? So can we talk about gluten and dairy? Because those two have been demonized, you know, now for the last probably decade, you know, I myself, I don't do that much dairy, but gluten, I do because, you know, I think there's a lot of myths about that for sure. So what kind of role does gluten and dairy play with your patients with autoimmune and rheumatic diseases? Yeah. So there is very little research in terms of elimination of gluten. There is some research in shrugins as well as fibromyalgia and these patients are more prone to having non-celium gluten sensitivity. So I already know that. So in those patients, I am extra careful and when I'm evaluating their food and symptom journal, I'm looking at like, okay, if they eat gluten, what kind of, you know, bread they're eating, what if it's like a non-processed gluten containing grain versus like a processed gluten grain or not, all of those things. And then based on that, I will see if there is an elimination needed. So in most cases, they don't need elimination. However, in some cases, I have to eliminate gluten if they have IBS as well. And talking about dairy, so it's very important to kind of unpack dairy because it's very complex. It has protein, lactose as well as fat. So a lot of times people say, oh, I don't tolerate dairy. I just eliminate the whole food group, right? I don't do dairy. I completely become vegan, right? So that is not necessary because in my grad school research on probiotics, I was looking at seeing whether the probiotic bacteria survives through the stomach acidity, the stomachs environment survives and go to the intestine to multiply, right? So I used like a simulated stomach model. And I use frozen yogurt as a matrix, which a lot of probiotic companies now encapsulate the probiotics in dairy matrix because research studies have shown that it does help them survive and multiply in the gut. That being said, fermented dairy is anti-inflammatory. So I will see like, okay, are you lactose intolerant? And if that's the case, let's do lactose free first and see how you're feeling, right? We can keep like the high protein low lactose yogurt fermented foods in the mix. And then kind of if we have to eliminate it, then we will eliminate a lot of times is also like, how much cheese are you eating, right? So that also requires a very individualized approach and you don't have to eliminate dairy and gluten unless it's a trigger for you. Jennifer, earlier you mentioned FODMAPs and you were just talking about fermentable foods. I think it would be worth explaining what are FODMAPs exactly and what would be like a high FODMAP diet and low FODMAP diet? So FODMAP actually is a low FODMAP diet is actually a medical nutrition therapy for patients who have irritable bowel syndrome. And the high FODMAP foods is kind of like a multiple buckets, right? So there's fruit cans, oligosaccharides, proctor oligosaccharides, fruits, grains, beans, lentils, nuts and seeds, honey, onions, garlic, all of those sit into this high FODMAP category. So people with IBS, they just need to do an elimination for four to six weeks and go on a low FODMAP diet and then we have to challenge to see like, because not all high FODMAPs are going to be trigger for them and again, that's why the individualized approach because when we do the challenge phases, when we exactly know what are their triggers and how much portion of a high FODMAP food can they tolerate. And once we know that, then we could do like the full reintroduction phase. Because we want to make sure they're getting adequate amount of fiber throughout the day and that's what happens. A lot of people go on a low FODMAP diet without supervision and they get stuck. They go on order immune protocol elimination, they get stuck because they are very afraid of reintroduction now. So that's why it's important to go through medical supervision with these medical nutrition therapies. However, order immune protocol is not a medical nutrition therapy. It's just a elimination restrictive diet. So when you're eliminating these FODMAP foods essentially, I mean, obviously, it would be pretty restrictive. So do you kind of eliminate all the foods that would classify as those FODMAPs and then slowly reintroduce one by one by one? What are your thoughts about maybe instead, if somebody's maybe, let's just say eating all of them instead of, you know, kind of reversing that and just eliminating one by one? To me, it just intuitively seems like that would be less restrictive and we're talking about sustainable nutrition and the habits that you mentioned earlier. I feel like for compliance, that would be easier to do. Have you ever tried that approach or do you know anybody who does do that approach? If so, which one is more successful for you? Yeah. So as a registered dietitian and as you guys too, we have to go by evidence-based nutrition. And like I said, okay, so medical nutrition therapy is, yes, this is how the approach needs to be and this is what works. If you do, if you go in other fashion, then it may not work, basically. And some, the other diets are more trial and error. So in case of low FODMAP diet, it is a medical nutrition therapy and it has a very systematic approach. Like I said, so we have to eliminate all high FODMAP foods. And again, the thing of it is, if you eat one-third cup of beans is low FODMAP, but if you eat one cup of beans is high FODMAP. So it's not as restrictive and then as a dietitian, I will make sure that they get all the foods that they need for their dietary preference. And then after challenging, we can definitely reintroduce whatever needs to be reintroduced. But if we just do one thing at a time, they're still having symptoms. So I don't know if this is better or that is better. What elimination works, right? So you have to eliminate all the high FODMAP foods first, yeah. I love that. You know, basically, we talk about how the dose makes the poison, right? A lot of times in medicine. And I think it was subocraties, right? I don't know if he actually said it if anybody proved it, but it was like let food be thy medicine and medicine be thy food, right? So that kind of just, you know, you mentioning that kind of reminded me of that quote. So I love that. So Jennifer, in the last several years, we've been seeing people, you know, through social media or whatever it may be through some research, really going towards one diet or the other, whether it's ketogenic, beginnuary and people being begins or Mediterranean diet, et cetera. There's just so many out there. Is there one diet that you've come across, either that you tell your patients to do or through the research that shows to be more anti-inflammatory than others? Yeah. Yeah. So in terms of diets, right? Like when we think of diet, it's more like associated with diet industry. I'm going to start a diet in January and then, oh, it's only 30 whole 30 or 30 day diet or all of that, right? There's a stop to it with my approach. It's more like eating pattern that I focus on and lifestyle approach, right? So there is no like, okay, I'm going to put you on a diet and then we're going to get off the diet, right? Of course, if it's a medical nutrition therapy, like low-part map, then we have to kind of start a medical nutrition therapy and then go into more anti-inflammatory nutrition. But I come from more of the blended approach of Mediterranean style of eating and then anti-inflammatory phytonutrients and omega-3s and herbs and spices like those specific nutrients that are helpful in reducing inflammation and healing gut, yeah. I love that. We recently had EC Sinkowski from Optimized Nutrition. You're probably familiar with her work and I think we asked her and maybe on a different one of her own episodes on her podcast, she talked about diets failing and essentially kind of what you're talking about. The term diet, when people hear that, they associate with something six weeks, maybe two months or something that's got that end point, like you said, and I forget if I'm getting to the quote wrong, so please forgive me, but she might have said, if you can't sustain a diet for six months a year or something like that, then that's not really what you want to be doing. And diet is kind of, again, the eating pattern, so I really, really like that, that that's how you approach it with your patients, clients and stuff. You talked about gut, you've talked about gut a couple of times now. So I'd love to hear your thoughts on basically the role of a healthy gut in reducing inflammation. We're talking about fermentable foods, we're talking about five maps, we're talking about inflammation. We know that the gut plays a crazy significant role when it comes to brain health, when it comes to general inflammation, when it comes to pain, how do you approach that? You're obviously taking care of a lot of people like IBS who have gut issues as well. What are your thoughts in the role that the gut plays with nutrition and pain and how are they all connected? So in terms of autoimmune chronic illness warriors, our research has shown that they do have a gut, which is basically like an increased intestinal permeability. So I like to tell patients like, okay, imagine like Swiss cheese, right? There are holes punched and that is now allowing like things from your gut to go into your blood, which is causing all this inflammation. So research has shown that autoimmune chronic illness warriors do have leaky gut as well as they have imbalanced micro flora. So the first thing I like to do with my clients is definitely eliminate the triggers because obviously if you have non-celiac gluten sensitivity and if you're eating gluten containing grains and foods, then it's going to keep triggering your gut and create more inflammation. So eliminate that first and then try to heal the gut with increasing fiber, fermented foods. With my population, I try not to encourage them to eat a lot of probiotic containing foods because a lot of them, we don't know the research. We don't know what kind of probiotics they have, what's the load of probiotic. We know that we need 10 to the 8 CFU per ml needs to go into our gut to be able to multiply. So we don't know about kombucha, we don't know sauerkraut, those are good to increase the diversity. However, they're also very high in sodium. That being said, fermented dairy is something I lean on very much so for my clients if they're able to tolerate dairy and if that's not one of their triggers. So helping them with increasing definitely omega trees, phytonutrients, fiber from whole grains, legumes, nuts and seeds, as well as probiotic bacteria supplement if needed. Gotcha, super cool. Yeah, I'm super fascinated with the gut and actually, I say this off from the podcast, I was originally interested in going to gastroenterology just because of the microbiome and the boom of it and how much it relates to everything else in the body. But I do have a question for you, is there ever a time where you refer your patients to go see like an allergist to get like a food sensitivity panel or anything? Great question. So actually one of the immunologist and allergist who practices in Ohio State University, she has shrugans and she actually did nutrition coaching with me because she tried autoimmune protocol first and she felt very restricted with that and so she came to me and she's like, please help me with a non-restrictive anti-inflammatory gut healing approach. And so she worked with me and she found my approach very useful and that being said, she is the one who screams on the rooftops and says, you don't need food sensitivity tests because they are not evidence based. Allergy is different. A lot of people, again, they use these words interchangeably, right? If you have allergy, you know, you have allergy, like you cannot just eat that food and be okay with it. However, intolerance also you would know if it's a GI intolerance caused due to dairy or gluten, stomach bloating, feeling like your 8 months pregnant or diarrhea or chronic constipation. So those things we can tell just from signs and symptoms. However, when you do food sensitivities test, she explains this better, but I'll do my best. It just basically detects everything that your body has been exposed to, right? So they're just not evidence based and whatever research we have is backed by the food companies or the companies that sell food sensitivities tests. And in my practice, like I would definitely use these things if they were evidence based and if my approach alone wasn't working, right? So there are some tests like for hormone and imbalances, like if I see someone who has PCOS, chronic fatigue syndrome, as well as an autoimmune condition. Then in that case, I might do like something called Dutch test. But again, very rarely, it all depends. It has to be a very individualized approach. Yeah, but I don't know that. Could you explain that? I don't encourage foods and... What is the Dutch test exactly? So Dutch test exactly kind of tells you like your estrogen, your progesterone, and it gives you like a whole panel of like different hormones and how all of these hormones are kind of the balance of these hormones in short, yeah. Sorry, when you're referring to the sensitivity, let's just go back to gluten real quick, right? So we're talking non-silia gluten sensitivity. That's kind of where there's no role in all these tests. But when obviously we can do serology for ciliac disease, right? That's not where you're talking about. Yeah, yeah, yeah, no, no, not at all. Yeah. Celiac diagnosis, it comes from colonoscopy, colonoscopy is like the most accurate, right? And a lot of times people with ciliac go with other diagnosis. And they come to me and they're like, oh, I have no idea. I didn't have any signs and symptoms. But when they come to me and I see a red flag, which is eye and deficiency anemia, they eat meat, and they still have eye and deficiency anemia. Definitely, their gut is not absorbing eye and properly. And there are, and also if they have like some digestive issues, like bloating and other issues. Then in that case, I would say, okay, let's see the gastroenterologist first and rule this out if you have ciliac. Gotcha, okay, that absolutely makes sense. You know, I wanted to transition to supplements. I know you mentioned magnesium earlier. And then you started talking a little bit about omega-3s in terms of the Mediterranean diet. Just came across a research paper actually that shows, you know, in terms of getting inflammation down, the Mediterranean diet probably showed the best because of omega-3s, but also reducing sodium intake. So obviously, I think most of our listeners will know, hey, omega-3s are great. Any advice you have in terms of getting optimal omega-3s in, and it kind of explains the ratio between omega-6 to 3? Okay, so in terms of omega-3s, let's kind of unpack that a little, because a lot of times people who promote vegan diet, they're like, oh, you can get all your omega-3s from your, you know, chia seeds and flax seed and hemp seeds. But your body doesn't do a good job of converting the omega-3, that is found in chia seeds, flax seeds, which is ALA type to EPA DHA. So we have to get both. Both are great. The most research is in EPA DHA, which you get from eating oily fish to two to three times per week. But if you have allergy to fish or you don't like the smell or you just don't like eating fish, then in that case, addition supplement would be helpful. So when it comes to omega-6 and omega-3, I'm glad you brought that up too, because I generally, I'm not emphasizing so much. Like, oh, let's just start focusing on reducing omega-6, right? Because people can get very obsessive with it, and because your walnuts have omega-6 too, like, and they have omega-3. So now it's like, okay, should I eat walnuts or not? So I emphasize more on like, okay, let's look at how can we improve your intake of omega-3s that will just take care of itself, versus like obsessing about how can I lower my omega-6? You know, there are some strategies I will look at, like in terms of which oil they're using for cooking and all of those things, and that's that. But with supplements, I would say anything above 750 EPA DHA, I generally like the higher dose, like over 750 for both EPA DHA, because most research studies have shown that that dose really helps reduce inflammation. Now, Jennifer, do you ever test people's levels? Cause I mean, I know that you can get the omega-3 index and kind of check your basins. Do you ever check it when you're kind of starting to work with somebody? So actually, this is also old research. This is not applicable anymore. The omega-3, the index, because we used to do that at a company that I worked before. We used to offer omega-3 levels testing, but there's so much mixed research out there that the testing can be very expensive, right? But we already know that omega-3 is like something that will get absorbed, cause it's fat, right? So it's not like, let's say it's not iron that it's gonna get absorbed in your gut, right? So that's why testing, I'm not a huge fan of testing unless somebody is like, yeah, I want to test, then yeah, sure. Let's do it, but usually it's not a common practice. Awesome, yeah, thank you for that. Now, I have to ask this question because all three of us have a South Asian background. So what about the role of turmeric, right, or curcumin? How often do you find yourself reaching for that as either a supplement or start upping the natural spice so people can start cooking with it for your inflammatory conditions? And which condition specifically have you found it to be the most helpful? Great question, if turmeric was so miraculous, South Asians wouldn't have rheumatic diseases, right? Cause it is still prevalent and we've grown up eating turmeric all our lives, right? But my mom still had chronic pain. That being said, number one thing, supplements are not regulated. So I, as a dietician myself, I was in a rush at the grocery store and I picked up quickly, picked up turmeric, a supplement without really looking at it. And I came home and it didn't have pepper in it. So it's not regulated and people are, if they don't know how to properly read nutrition facts label, they're picking up turmeric supplement and if it doesn't have pepper in, they're just pooping it out and it's not providing any health benefit to them. That being said, I'm like, let's just check off all the boxes on like anti-inflammatory nutrition. And turmeric can be part of your diet but we don't have to have golden milk every single day if you don't like it. If you do, then definitely I support it fully. I didn't like it as a child myself. And then what makes it taste better is like some people serve honey sugar, right? So that just kind of defeats the purpose. And most research is done in mice where they use curcumin, which is in high amounts, right? And it's very hard to get that much curcumin when you're just using turmeric powder because turmeric powder doesn't have all the high amount of curcumin that we need, right? It's the concentrated bioactive compound that's curcumin in turmeric. So you can definitely add turmeric powder but make sure you add pepper to it for any anti-inflammatory benefits. But that's a supplement I reach for very, very carefully because it can cause diarrhea. And it can also cause miscarriages in women who are pregnant. So if they're just, if they have rheumatoid arthritis, they are taking turmeric pill and if they're pregnant, then it can cause issues. Wow, dammit, that's scary right there. I didn't know about that one. Is there a lot of literature supporting that or are those kind of like case reports or is there? Great question. Research, I keep up with it, but I would have to look like whether it was more of a double blind control trial or more like a case study, but I can get back to you with that. Yeah, no, I would, I mean, that's a pretty scary one. And I think that yeah, I would definitely love to see that if there's any paper kind of showing those kinds of complications and reports, I will say though, I think in our world where we see a lot of knee osteoarthritis, there is a lot of literature coming out more and more and we're talking good gold standard double blind randomized control trials, although the sample sizes aren't that big. And then you know, it really depends on what your feelings about, who funds the research and not we recently had one of my mentors Dr. Arnt come on here and talk about how maybe looking at the methods of a study versus necessarily who funds it is going to be more important because at the end of the day, like, and you talked about dosing, right? You talked about, we talked about efficacious dosing before dosing make the poison and yeah, you can't necessarily get 500 milligrams through times a day. We know for osteoarthritis, 1500 milligrams of curcumin with pippering, kind of black pepper, what you described for absorption is really what does affect. And that's the only one that I'm familiar with it, but I mean, it's definitely not first line. It's definitely like three, four. Obviously weight loss is going to be the most beneficial, which is something you've already touched on. I will tell you though, we actually recently learned this ourselves because Dr. Arnt came on and talked about that actually supplements are FDA regulated. Now, they are under, the FDA has this 101 page that actually they regulate them, but they're very poor quality control. They're under a different review called the FTC. And so essentially it's extremely poor regulation, but basically what they're regulating for it is to make sure you don't have these catastrophic side effects or complications, kind of like the risk arid or something like that that you talked about. If they see that post market surveying, then they would pull these supplements off and that kind of sting. So the issue is because quality control is so bad on this, you don't know what you're getting. Like for instance, even within one supplement bottle, you could get, for instance, a melatonin, let's just take that, right? Like, there's literature showing that when independent companies do an analysis on a melatonin bottle, if it says three milligrams, you could have anywhere from like 30% of the dose that's listed on the label versus up to 400% of the dose. So you know, that's the issue. And I think that even myself up till about a month ago, I kept using the same term, hey, if they're not regulated, then I regulated it. And I think we're all, we all mean that they're poorly regulated, but that was just an interesting thing that Darshan and I learned. But I wanna shift gears a little bit, because we touched on anti-inflammatory nutrition. We've talked about grazing. We've talked about, you know, intermittent, we haven't talked about intermittent fasting, but I would like to hear your thoughts about fasting as an approach for an anti-inflammatory or pain mitigation strategy. You know, both Darshan and I listened to Peter Atio respect him a lot, and he's had a lot of people come on and talk about how, when they go on these prolonged fasting approaches, like three days, four days, five days, anecdotally, a lot of them report that their joints don't hurt, they don't have aches and pains anymore. Have you used that as a strategy for anti-inflammation or anything like that and just your general thoughts? Yeah, so there are not many research studies in intermittent fasting for autoimmune and rheumatic conditions. However, there was a study that looked at intermittent fasting and they saw that the warriors who did intermittent fasting had lower levels of pro-inflammatory markers and better insulin regulation. So that being said, you know, again, the question I would ask is, is this sustainable? If it's supervised and if it's done correctly, it can work like even in diabetes patients, PCOS patients, it does help with that insulin sensitivity, which eventually helps with reducing inflammation. In my approach, like I said, it's more of addition versus, okay, now let's go to another strategy, right? Like, first of all, they don't eat breakfast and second of all, they have very low appetite. Third of all, they are already struggling with medication side effects. And number four, it's not sustainable. So I really don't like to go into those strategies unless I see that the person is like extremely self-motivated. They've checked off all the boxes on anti-inflammatory nutrition. And now this is something extra that they'd like to do. Yeah, but I mean, there's always gonna be research on, like there's research on keto, there's research on everything, right? But it's all at the end of the day what works for your patient and how sustainable it is. I love that. Yeah, absolutely, I tell people all the time, so many people asked me for a protocol for fasting and I say, it really depends on the person. You could do a seven day and feel like crap or do a five day and feel amazing. You could do five, two, you could do 16, eight, and I tell my story where I was doing 48 hour fast once a month last year. And now I kind of just do a 24 hour once a week and actually today and tomorrow, I'll be doing a 24 hour fastness because I feel so much better and I think people have to fine tune what it is. But I like how you said it's kind of like an adjunctive thing afterwards. So I know you wanted to talk about your top three anti-inflammatory tips. What are they? Yeah, so tip number one is guys, just hydrate, don't forget hydration, don't get too busy. If you don't like plain water, there are many other strategies you can follow to get that water in. It does play a huge role in inflammation. Number two is e-balanced meals. So your blood sugars are pretty well balanced throughout the day. Definitely, you need to fast between meals for sure. That's why we say it's the opposite of grazing because you don't want to be grazing. A lot of people make this mistake where they are grazing and they continue to graze and they're never satisfied. When you eat balanced meals, you get the opportunity to fuel your body properly with that protein, healthy fats, fiber, all of the good stuff. And number three was prioritize me time and sleep, right? Because living in chronic stress may seem a norm, but it's not normal. Like we just think, oh, if you're not stressed, we're feeling like formal, right? Like, oh, I'm not stressed. Is there something wrong with me if I'm not stressed? But actually, there's so much research to support that stress plays a huge role in creating inflammation in your body. And creating anxiety and lack of good quality sleep. So, hydrate, eat balanced meals. What's, yeah, prioritize me time and don't consider stress normal because it's not normal. So I like that, right? Because we know stress affects the gut, affects the adrenals. We got all holistic care here. The body will undergo that inflammation otherwise. And especially here in a Western society living, especially with COVID, hopefully our listeners can definitely take away that tape. I really do appreciate that advice. Any final thoughts you have here, Jennifer? I would say, guys, just go follow me on Instagram. Everyone enjoys my dumb dance moves over there on IG deals. So go follow me. You will get some evidence-based nutrition. And my handle is chronic pain nutritionist. I'm on clubhouse too. So if you're on clubhouse, I'm autoimmune RD on clubhouse. And I do have a free Facebook group. And I'm gonna start, actually, I'm starting a three-day mini series in the private Facebook group. So if you guys want to provide information, it's called nourish to flourish nutrition and lifestyle community. And you guys can find me there. Fantastic. Yeah, I think we met on clubhouse and that's kind of how we got you on clubcast. And yeah, we'll link all those in the show notes. Awesome. Yeah, thank you so much for joining us, Jennifer. I know this was really informative for me. I know I learned a lot and definitely had some fun talking. So hopefully our listeners will take away some valuable tips from this. You're very welcome. I appreciate you. Appreciate you, Jennifer. Thank you so much. You're welcome. Everyone, I really hope you enjoy that show with Jennifer. But before we end, don't forget to reach out to MR Insurance Consultants, where their goal is to assist physicians in obtaining the most comprehensive coverage available to fit their unique situation. Reach out for both excellent and quality service at doctorpodcastnetwork.com or slash MR Insurance. And I'll time for that quick disclaimer. Everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient relationship is formed and anything discussed in this podcast does not represent the views of our employers. Again, everyone, if you found this to be beneficial, please send it over to your loved ones, your friends, your family, whoever you think can benefit from this chronic pain. I think it's something that we all deal with, something in our lives. But at least we know that there is some sort of solution with the things that we put into our body in our diet. So feel free to rate, subscribe, share, whatever needs to be done to spread the information. Thank you all.