The Biggest Lies We're Told About Supplements | Josie Porter

0:00Dr Karan: We're told a lot about the supplements we should take, but very rarely told how not to take supplements. That's why I'm joined today by food first dietitian and GLP One specialist Josie Porter. I find this the problem with supplements being marketed as like the natural alternative or just like as natural anyway, because they're not natural. A lot of the time they have higher doses than your body would normally get from a food. So it can definitely have consequences when you're putting too much in. Not everything is just urine out. I'm Dr. Curran, and in this podcast, I speak to the world's foremost experts in science and medicine to cut through the BS of modern health advice.

0:34Dr Karan: Thanks to Loam Science for sponsoring the show, the world's first invisible fiber blend with clinical trials. Josie Porter. Hi. You're a specialist dietitian. You literally wrote the book on supplements, or at least how not to take supplements. If I looked at an average influencer's drawer or kitchen cupboard, what sort of supplements would I find? I mean, it could be anything and it could be a number of them, I feel like. Some of the ones that seem to be getting discussed a lot at the moment are electrolytes. I think you've probably seen loads of that yourself. Like everyday hydration, even if you're sitting at your desk, when actually this is a supplement that's been recommended for people doing high intensity sports, sweating a lot, there's no need for that sort of daily hydration.

1:16But also I'm seeing a lot of like magnesium, for example. It seems to be the cure-all for everything from your sleep to migraines to even blood pressure or recovery from exercise and stuff like that. But yeah, so many different things. Creatine, of course, is another really popular one that I think a lot of people are taking, not just for exercise performance, but a lot of people are very interested in like the cognitive benefits that seem to be getting shared around social media as well.

1:40Dr Karan: So I want to touch on the electrolytes first. It's like, you know, I'm glad that you spoke about that. So I've never taken electrolytes regularly. I sometimes tried them on like a really hot day when I just want something sweet. but then I regret taking it because it's just so high in salt. I've got a family history of high blood pressure so I definitely, I'm getting older as well, 36 now. So I definitely am at that age where I check my blood pressure once a week just to make sure that it doesn't sneak up on me and get high. So electrolytes is not in my stack. But it's interesting you said the words daily hydration because that is one of the sort of headlines I hear when these electrolyte companies are selling something.

2:20Dr Karan: Now, I do have a friend who has an electrolyte company, so I don't want to slate him too much, but I do want to get to the real science of electrolytes. You said that there's certain people who could benefit, but talk me through this sort of marketing that's used where electrolyte companies and influencers who promote electrolytes make it seem that there is a use case for some sort of daily hydration for the average nine to five office worker or the average person just at home doing not much intense activity. Yeah, I mean, I guess the thing is, right, these supplement companies want you to take it every day because then you're buying more.

2:57If you're only doing it when you're sweating a lot, which maybe it's like once a week, twice a week for some people, maybe more for some other people. Even so, it's not going to be every day that most people are sweating, right? That means you're not going to buy it and replace it and replenish it as much, right? So you're not investing as much money. But if they can sell it to you as something that you need to take every day by adjusting the quantities of sodium, for example, which I'm seeing a lot more at the moment, then, you know, ultimately, I think that's one way in which they're doing it.

3:21So I'm seeing a lot more electrolyte brands now saying, no, it's for every day because we've reduced it. It's not just salty water. And actually, you need these minerals in your water to help you with optimal hydration day to day. When actually you look at the evidence, there isn't any magic ratio for daily hydration. The most important thing is drinking enough water. And even big societies like the Sports Society who do lots of statements around optimal supplements for hydration and hydration strategies, they don't even recommend electrolytes for most athletes as well so why would you need it if it just sat at your desk every day the main thing is definitely always going to be water and on that

3:58Dr Karan: thing about the hydration as well there's this kind of additional bolt-on myth that kind of like seems to be reverse engineered that water doesn't hydrate you and which is why you need the electrolytes on trop and they they seem to take a molecule of cellular physiology you know osmosis and water gradients to then kind of like reverse engineer that into saying that you need these exogenous electrolytes to draw water into the cells. And they've kind of mutated basic physiology into something that suits the commercial incentive that they're trying to flog. Yeah, exactly. No, I agree with you. That's exactly what they're doing.

4:38They make it sound really scientific in these adverts that you see, but ultimately it doesn't work like that. When you look at studies, they don't support that. Actually, you need to have a magical ratio of these electrolytes. Of course, if you are sweating, then you're going to be losing a lot of sodium and chloride, which is basically table salt. You might lose a small amount of potassium and magnesium, but it's very negligible. So you should get that really through having enough balanced foods throughout your day. So you know, like your whole foods, like your beans, pulses, nuts, seeds, grains, things like that are going to be really important for helping you get the rest of those minerals.

5:10You don't need more. More is not necessarily better. A lot of these minerals are also controlled. So if you're having more, You're just going to get rid of them, essentially.

5:17Dr Karan: I also I've seen a lot of electrolyte brands use pink Himalayan salt in their ingredients as like, you know, something as like a exotic alternative. My concern around some of the kind of these pure salts that a lot of brands use, whether it's like Celtic sea salt or pink Himalayan salts, is that because they make the comparison to table salt. You know, the table salt that we use to maybe season our dishes is refined table salt. So it's been through a purification process to remove some heavy metals. But pink Himalayan salt is unrefined. It comes from regions where it's not been purified or processed, which sounds nice and natural.

6:00Dr Karan: But then it could be contaminated with excess heavy metals, which we don't want. We want to try and minimize. Absolutely. Yeah, that's a really good point as well. So you don't always know what you're getting with some of these products that are more natural. Natural isn't always better. Like it just means we don't always really know what contents it has in it. I mean, and at the end of the day, even if it is to consume it for a few extra minerals, how much salt are you actually consuming? I mean, you're going to get a negligent amount of those extra minerals anyway. So still whole foods you eat in bigger portions, like again, those whole foods I mentioned earlier, are going to be the main thing that is going to give you like a meaningful dose of micronutrients.

6:32Dr Karan: I think, you know, if probably anyone is taking regular electrolytes, certainly the kind of electrolytes that are, you know, a thousand milligrams of sodium plus, probably worth some sort of weekly or monthly monitoring of their blood pressure levels. Yeah, absolutely. Particularly if you're someone that has maybe more processed foods that have more added salt or even if you are having a lot of whole foods and you're adding a lot of sodium, like salt even, sorry, while, you know, you're cooking and things like that. Definitely worth it because it can really sneak up that sodium. and some people are definitely more like sodium sensitive like women for example as well so really worth yeah looking at you know yeah you can really creep up on you you mentioned the creatine as well as another thing um i take creatine when i remember to i wouldn't say that i'm like a regular creatine user and you know it seems to be one of those things that everyone says it's the most widely researched uh supplement and you know it may well be you know have some good research you also mentioned that a lot of people are now exploring the cognitive benefits.

7:31Dr Karan: This is something where I think there's a bit too much hype and hyperbole, because I think if you say the standard three to five grams of creatine, that's where the most research is in performance and stamina and, you know, muscle support. But then if you go to cognitive and the neurological benefits of creatine, that's where there's a lack of research. And I don't think there's a wide repository of data on 10 grams plus right no i agree with you there's really not a lot out there i mean there was something recently around sleep deprivation so obviously quite a niche situation for some people at least i know some people have less sleep but it's not the same as sleep deprivation right so there was a study where they use like a single dose and it was a high dose i think it was 0.2 grams of creatine per kilogram of body weight so for an average person that might be just over that 10 marks to say someone's 70 kilograms that's like 12 14 if my math serves me right so a slightly higher dose acutely and they found that that did help with some of the side effects of sleep deprivation that's probably one of the more exciting studies but it's really small so it's very experimental it's not something that is like a blanket recommendation at this point and then for other cognitive benefits maybe there is some benefit for those who are older adults but actually when we look at it in healthy younger adults there's actually some evidence suggesting the opposite that there's not a significant change so again i just really don't think it's a blanket recommendation for everyone and actually you might feel like you have benefits of brain fog when taking it but that could just be placebo and you know there's nothing wrong with placebo i mean if you feel better that's great but ultimately if you're not actually getting objectively better there's not objective measures that are better you're kind of selling yourself short and you're paying a lot of money for something i i wonder something with creatine especially that high dose And then, you know, I came across that sleep deprivation study as well.

9:16Dr Karan: And I just wonder, it's such a high dose. I presume someone is going to be taking a lot of water with it. And whether the effect of hydration is a confounding variable which helps mental performance. Because we know, right, even mild dehydration can affect your cognitive state, like, you know, your reflexes and all these sort of things. So I wonder whether that's a component. Yes. I always say this as well. Like, there's the water sometimes you mix things with. Like, when green powders were coming about and people felt that they felt better. Yeah, it feels a bit older now. The greens powder stuff, like it's kind of now about outdated.

9:47But even then, I was like, it could just be the water. If you're having it with 500 mil, as I normally recommend, that's going to help.

9:52Dr Karan: Yeah, exactly. That's a decent amount. I guess the creatine story, it's an interesting signal from a cognitive performance thing. And maybe that's like, okay, we should do more randomized trials on this. Looking at that, maybe in women specifically as well. I've seen on the sort of opposite side of things, a bunch of videos of people with endometriosis talking about how creatine worsens their symptoms. And again, you see the other side, right, where there's this huge health halo around creatine. It's like this can do nothing wrong supplement. Amazing. Which maybe there's some truth to its kind of wide reaching effects.

10:27Dr Karan: But also some misinformation can creep in as well. where I think there was some mechanistic studies and some cell studies and animal studies looking at creatine in these kind of like non-human studies showing some proxies and how it can affect endometriosis. But then there's no human data on endometriosis. And I suspect actually that's a very personal thing. If you don't like it, it doesn't suit you. Don't take it. But otherwise, don't say it's bad just because of an N equals one piece of data. Exactly. Yeah, I've been looking at the endometriosis data with creatine as well. But as you say, it's not in women.

11:03There's no studies in an actual female body living with the condition. So we don't know. Again, it's exploratory. You know, you could experiment with it and have your test done and see how you feel with or without it. But, you know, equally, it's a personal choice. Creatine isn't holy water. You don't need it anyway. You know, when you look at the data for like resistance training and sprints, yes, they can have small to modest benefits. But for a lot of people, it's probably not transformative. And actually, yes, we might see gains in lean mass, but lean mass also includes water. And we know that obviously we can get more water into the cells.

11:33So while interesting with creatine, don't feel like you're missing out if you have endometriosis and you're a bit worried. You know, again, we don't know, but equally don't feel pressure to take creatine just because social media is raving about it. Because the effects are still quite small to modest. It's a good edge if you're an athlete, sure, but probably not going to be as transformative for some people.

11:52Dr Karan: now obviously those are just two of a vast swathe of supplements out there what are some red flags on supplement labels that you should be aware of yeah i mean labels and like i guess it's like advertising and websites and things like that i think one thing that i'm seeing a lot of is what i call science washing so kind of like green washing you know when brands kind of make it out that they're being sustainable i feel like brands are making it out like they're being scientific but they're not doing their own research they might have a study you know it a supplement, sorry, that has multiple ingredients.

12:23And then they're linking on their website, we're evidence-based. And they've got tons of different papers, but of like the individual ingredients at different doses with different populations. Then they're mashing all together to say that this combined ingredient, you know, multi-ingredient supplement that we have is evidence-based, but it's not. It just proves that these individual studies have some evidence for these individual ingredients for certain populations, but that doesn't make you all of a sudden science-based.

12:49Dr Karan: I think that's such a huge point to make because, you know, when I was like formulating loam as well, we went through the same process. And I think like I think about like the evidence is different tiers. If you're making a supplement or taking a supplement, the fact that it has clinically backed ingredients individually is like tick. OK, great. That's like step one. You've done that. But then you should not be claiming that your synergistic blend is somehow able to piggyback off those. Right. The tier two is go and do one study on your thing. And then tier three would be do multiple studies in different populations on your individual thing.

13:30Dr Karan: and you know like certainly for me um i i want to build what i'm doing for skeptics and we obviously use clinically backed ingredients and then we had you know the first human study and just a normal healthy population on this and then as we got feedback from people saying oh it anecdotally helped with this with how then we're like okay let's do a disease population study to have a look at that so like you know on the topic of endometriosis we just got an ethics approval to do a study on endometriosis because we had a lot of gps writing in being like oh yeah i'm actually recommending this to my patients with endo and they're anecdotally experiencing some benefits so we thought okay let's do it yeah and i think you know when i'm like taking you know like a supplement or whatever i am looking if it's a blend has it got data beyond just piggybacking off something else i think that's so important yeah it is really important and i like what you say about the steps like the tiers of like evidence i guess but like that tier one or step one is really the bare minimum that is really important to do but yeah it's great that people are doing more research and I appreciate that studies take a long time.

14:31It takes a long time to get a study peer reviewed and published to recruit people for them to finish. You know, there's always dropouts. It's not easy, is it?

14:39Dr Karan: Yeah. No. And I guess also if you're in a state of deficiency and you take a supplement, it can be lifesaving, transformational and really improve your quality of life. You know, if you have vitamin D deficient and then you're sufficient, if you're B12 deficient and then you're sufficient, huge night and day improvement sometimes. but then going from sufficient stores to excess there's no additional yield often and sometimes it can be worse right like the same supplements which help you with one thing can actually worsen something so like you know my uh four and a half month old we're giving him like daily vitamin d drops right and i think because he like draws some of the stuff out my wife's like giving just a little bit more and he's now not pooped in three days and that might be because he's got too much vitamin d so okay let's like dial back so you know that's the kind of like opposite side you know where actually excess of certain things can cause complications and then you go out of optimal range to then you've got side effects well yeah this is a thing and i find this the problem with supplements being marketed as like the natural alternative or just like as natural anyway because they're not natural.

15:50A lot of the time they have higher doses, not always, but they have much higher doses than your body would normally get from a food. So it can definitely have consequences when you're putting too much in. Not everything is just urineed out. Iron can be stored in the body. Too much vitamin D can impact things like calcium in your bones. Zinc can interfere with copper. So too much is not always a good thing. Biotin interferes with certain lab markers, for example, as well. So yeah, it's not a good thing necessarily to have too much.

16:19Dr Karan: I want to talk about something that's quite personal to me and about some medical conditions that I suffered from. I used to have high cholesterol and fatty liver disease and that primarily stemmed from a severe lack of fiber in my diet. And on my quest for finding the perfect fiber supplement over the last few years that could help me add more fiber into my diet, I couldn't find one. That ticked all the boxes that I wanted and the high bar that I set for myself. So I built Loam Science. What I'm most proud of is not the product. I know that's great, but it's the fact that we've run two clinical trials on it, two randomized controlled trials, which is far more than the vast majority of supplements on the market will ever do.

16:54Dr Karan: And we've got even more coming because I'm a doctor first and foremost and a scientist. And I wanted to build something that I could actually stand behind with data and not just rely on good branding. So if you want to understand what's inside Loam Science and why, the science is all on the website and the link is in the show notes. do you have any particular opinion on you know the way these prenatal supplements are marketed because you know before my wife got pregnant in that stage when we were trying we were also researching like a ton of prenatals and you know like she's a doctor as well and we thought okay you know we're gonna like really do this properly and see what's out there and there's a lot of very I don't want to say the word predatory but it very forceful marketing yeah to try and make you feel bad about certain things where it's like especially around folate and folic acid we know that folic acid is important for people trying and you know in pregnancy for preventing neural tube defects and spina bifida and there's this thing where supplement companies say no you don't need folate you need methyl folate you know because it's better for you it's more bioavailable and I before I was kind of like looking at this for my own family I kind of like assumed oh yeah that makes sense and I'll get it and it's a premium and I'll pay the premium for it but actually most of these obstetrics and gynecology guidelines they don't say anything about methyl folate and it's like a you know it's like this mthfr gene mutation because of that you need the methyl folate which is absorbed and the more I looked into it I realized like that is a rare mutation and for most people the normal folate is fine and even with people with the mutation there's still a percentage of the normal folate they can still absorb so i was like okay that's actually really aggressive marketing about the methyl folate versus normal folate well this is a thing i think and i've seen that as well but i think some of these companies maybe see one paper or one fact like you say about the gene and then they they ride on that and be like right this means everyone needs to now take this and has a benefit from having methylated supplements when actually that's just not the case and yet again they are a lot more expensive yeah you know as if having a baby isn't expensive i know you know yeah you could probably cut down on the cost there yeah something simple is normally enough like folic acid yeah makes sense totally you know should be taking that ideally preconception of your planning yeah and into the first trimester you you talk a lot about in your videos you know iron and iron supplementation getting it from food supplements as well and especially in like young women i think young women certainly in the uk there's a significant proportion of young women in sort of 20s to 40s and even younger who are not meeting the intake amounts for iron but also equally it's not possible to get all your iron all the time well if you're deficient in iron like clinically deficient in iron it's not possible to replace that just from food alone so what is the use case and indication for iron supplements you know if someone needs that yeah i mean the best person to speak to is always going to be a doctor if you have any symptoms of course uh like you know low energy is a really common one people might experience changes like their hair their nails and things like that so the best person to speak to if you if you feel like you have symptoms of it is obviously your doctor and get your test done properly they will check things like your ferritin iron stores hemoglobin they will check things like you know even inflammation as well potentially too i mean it's up to them to decide really um but go to them see what's needed if you are low they'll recommend the best thing for you and as you say i mean when you are really deficient the best thing is going to be like an iron diffusion maybe or an infusion sorry or like yeah supplementation and i guess that's really up to your doctor to decide really you know the average person is probably not just deficient aggressively deficient in a wide range of things and assuming everyone can get like a wide range of food and a variety of things in their diet they'll probably be you know topped up with things what are some staples that in your pantry are like a pretty you know good range of things that you know most people should have which should cover like a wide variety of nutrients yeah and i think ultimately if you're eating a mostly a diet of like whole foods and varying up fairly uh you know a fair amount throughout the week you're going to be lightly covering a lot of bases in terms of like okay you're probably gonna be getting enough fiber protein different types of protein as well getting different amino acids but then also what i call like well you know micronutrients so the things that you need are in small amounts but still really mighty so your vitamins and minerals and things like that you can also get more compounds so you're not going to get a deficiency of things like polyphenols for example but getting those in your diet is also really beneficial we know for things like you know your heart health gut health stuff like that so yeah how to get those things about overthinking it it's thinking about key food groups like your whole grains are going to be really great they tend to be really high in things like prebiotics as well so things like your oats for example buckwheat barley quinoa is also quite a good grain going for the more whole grains over the refined grains you know having more refined grains can be linked to lots of different things even like immunity for example some really interesting data great for your guts as well but yeah then also your nuts and seeds so i love nuts and seeds i put them with every meal i love them uh the more the better really so you get a broad range of different nutrients because different fats sorry different nuts have different fat profiles for example uh seeds as well some are higher in magnesium some are higher in things like selenium so you know like your brazil nuts famously are quite known for like selenium for example i love pumpkin seeds for magnesium so getting a range of those in but also beans and lentils i love them i love me yeah yeah yeah i absolutely love them i'm putting them in all sorts of weird places at the moment in the pantry uh so yeah so i love anything like that they're normally a really pretty good source of magnesium but folate as well fiber and also protein like most beans contain a fairly equal amount of fiber and protein it's a really great addition to just throw into things like even i've been putting them in granola you know why not so yeah i've been messing with um bean smoothies recently oh i haven't yeah yeah just like some uh like butter beans which have like a creamy texture and like they're the least kind of like got the lowest taste profile yeah and i've just been blending some butter beans into like a blueberry smoothie or something you can't even tell and And especially if you have like a strong flavored smoothie, like a chocolate smoothie, you literally cannot tell.

23:12Dr Karan: Yeah. It's like when people are putting avocados in like chocolate smoothies, you know? Yeah, I do that as well. That's insane. Yeah. Avocados, great for fiber. And also, I also love having some dairy in the fridge at all times. Good quality yogurt, cottage cheese, milk as well. I love like even normal cheese like Parmesan. Great for getting things like, you know, your iodine, for example. Obviously B12. It was a plant-based alternative. So if you get fortified, they're really great as well. You get some live cultures and I also really love eggs as well. Eggs for choline. Got to have some eggs, you know.

23:44Dr Karan: So nowadays, there's this kind of school of thought, right, where I think there's a spectrum where people think that food is medicine. I don't fully agree with that. And then there's medicine is medicine, which, yeah, obviously. And then there's like something in the middle where food and diet can be transformational in many people's lives. who are eating significant ultra processed food, low fiber intake, high saturated fat, and then they change their diet, they can improve certain metabolic markers like LDL, cholesterol, blood pressure by changing diet alone sometimes. And sometimes you need medications and there's like a middle ground, right?

24:20Dr Karan: And given that kind of like food is medicine, there are certain things which maybe it has some molecule of truth. Like, for example, there are certain foods which can definitely help your gut health and help with constipation, you know, regardless of medicines. And there are some foods which are kind of equivalent to laxatives in their potential, like, you know, kiwis and, you know, certain things like that. And in studies, you've got this wonderful series called Hot Girls, you know, is it a hot girl poops or hot girls poop? Hot boys can poop as well. Hot girls poop. Yeah. And you've got like some really, you know like tasty looking things in that thing talk me through some of the food recommendations that you know you'd advise someone to start including if they had you know gut problems and constipation problems yeah and you know i totally agree with you that i don't think food is necessarily medication but this is an area where actually there are quite a lot of like first-line strategies that you can try before thinking about medication so i mean one of the key things really for constipation is looking at fiber like the amount so studies tend to suggest like around 25 grams a day is a good starting point for laxation so going to the toilet and obviously the recommendation for general health in the UK is 30 grams so that is important but sometimes some people can be there and still struggling and I do see that in clinics sometimes as well so if that is the case I might be looking at the fiber types sometimes people might be making up their diet of lots of insoluble fiber like wheat bran and foods like that and that could maybe sometimes make the stool quite hard still and not necessarily as easy to past if they were having maybe a good amount of soluble fiber with that so you know things like oats kiwis and things like that can also help to soften the poo and make it easier to get out so i like to also look at the split of fiber sometimes that also makes a difference as well and then things like hydration so you need that water just to help push things along and actually i feel like that often gets neglected often in the morning as well when actually we know that people are more likely to have that bowel movement those muscle movements are more likely to happen so getting some good hydration in the morning and slowing down is often what i always help you know i ask people to sort of think about if they are getting enough fiber in their diet just slow like routine habits like that can also make a difference like slowing down hydrating letting your gut relax if you're constantly in stress mode your your gut's not going to be digesting as well so those little hacks are some of the things that i look at there are some really great foods that have evidence behind them like kiwis as you've mentioned like two a day a really great strategy for getting some bowel movements going hopefully for some people yeah won't always work but foods like prunes have good evidence but it's quite a high dose so not great if you're someone who has ibs and might increase some of those symptoms but they haven't done studies on lower amounts of prune so who knows like they might you might still get some benefits of 50 grams but we just don't know i yeah i really like your point about this focus on you know different fibers and the diversity of fibers because even when I was you know years ago and I had high cholesterol I was you know I worked with a dietician to kind of like help me figure out how I can increase my fiber and one of the things she kept running into me was about the different fibers and even though it wasn't published data back then in 2018 and it was kind of newer data she was still talking about that sort of data that was kind of clinically applicable even though it wasn't published.

27:37Dr Karan: And the portfolio diet was like a more recent thing where they talked about different things that can help with cholesterol specifically, like, you know, very soluble fibers, the mucilage, you know, I eat a lot of like mucilaginous fibers, like, you know, like okra, which has that kind of like stickiness and the chia seeds, which is great for binding cholesterol and reducing the cholesterol. Yes. And the opi-toglucans that you mentioned as well. And so if you just stick to one type of fiber, you don't really get that diverse range of benefits right like so to your point you were saying if someone's got constipation and they're just having lots of wheat bran which someone thinks oh yeah wheat bran fiber huge amount of insoluble fiber and just backing them up and bulking without any of the laxation effect without any of the motility effect maybe without the prebiotic effect that helping your microbiome so you're targeting one aspect of constipation right and constipation is multimodal which is why you need those different fibers and you know that's for constipation but for cholesterol for heart health you need those other avenues to work and i always think like that's what people don't really understand they think one nutrient does one thing you know fiber does this and i should just have fiber from any one source and i'm good yeah no i agree with you getting different fibers is really beneficial and you know it's not even just about soluble and insoluble like the fermentable fibers like you mentioned super important for things like there's metabolites that your gut's going to release like your short chain fatty acids butyrate and stuff like that super important as well even for things like your immune system so yeah uh you really want to make sure you're getting a different types of fibers not just fiber maxing on one thing or like i think some people might be tempted to take a supplement with just one type of fiber like psyllium husk great but you're not going to get the whole benefits of having five different types of fibers for example um and you know some foods will also contain a mix of them like a lot of foods will contain insoluble and soluble fiber so you don't need to get too pernickety about it but yeah it can help to have a sit down and think okay i'm constipated i'm reaching my fiber needs but um maybe i need to just look at where i'm getting my fiber from and how can i diversify it a little bit get some of those soluble fibers some of the fermentable fibers maybe as well yeah for sure but again some of them do contain a mix as well especially the soluble and fermentable a lot of people these days, you know, I guess maybe it's how the foods are presented to us or just like how appetizing they are.

29:57Dr Karan: They do struggle with cravings and appetite. And, you know, like food is fundamental to kind of helping people regulate their appetite to some degree as well. In your opinion, working with your compliance, what are the best foods to really help with appetite regulation? Yeah, I think really there's a few different things. So appetite can absolutely be like physical hunger where you know your stomach's rumbling but also it can be sort of that head hunger some people will also add in heart hunger but i think that's quite complicated but head hunger can also just be because you're sort of craving you don't necessarily need them but you can sort of want them so i think it's a balancing act of both people can feel like okay they're controlling their appetite is probably because they want to regulate their weight in one way or another and sometimes when people have those goals they might be tempted to over restrict and ultimately i think when you over restrict particular foods or just going to learn calories as a whole regardless of where that's from ultimately that can drive some of those cravings that hunger and just regulate things so i think it's really important to if you're thinking about your appetite have the foods that we know are going to help keep you full but don't restrict those foods that also give you that mental pleasure as well so don't be over restrictive but certain nutrients can help your appetite more than others like you know protein digests really nice and slowly so that can also support appetite it's not you know magic though if you're really low in calories and you're getting that all from protein you're probably still going to feel hungry because ultimately if you go too low in calories your body's going to be hungry regardless fiber also will help as well stretch your stomach give you that sensational fullness so that can also help you with your appetite regulation but again it is also just really important that you're enjoying your food as well you're not being really restrictive because that's just going to lead to that scarcity mindset where okay i kind of have that chocolate bar and then eventually one day just going to cave in and have eight of them so don't do that yeah it's i see these like um you know meme videos online where it's someone is like really hungry and wants to be healthy and they have like instead of having like a chocolate bar they have an apple and they have the apple and then they ended up eating a chocolate bar and a whole box of pringles or something as well so it kind of like to the point of if you have this mental hunger where you just desire the chocolate bar or something like that, you know, probably just have that.

32:09Dr Karan: And that's not going to make or break your entire day. And I feel that as well. Like if you're sometimes craving a certain food, you're not just craving a certain number of calories, you're specifically craving that kind of food, which no other macronutrient may satisfy except that. And I've also found for me as well, sometimes it's a certain consistency or texture that I'm craving. Yes, yeah. You know, like you know that yeah like that sort of cottage cheese type consistency sometimes i just want something like that and even you know if i have something else it doesn't quite hit the spot because i really wanted something like that something cold and that texture that was slightly processed in a way you know that sort of food matrix was in a certain way versus like a harder food and i don't know if that makes sense no that totally makes sense uh i definitely i mean i feel like i don't have cravings that much but i feel like cravings often are as a result of maybe restricting stuff a little bit some cravings are normal for sure but if you're having really cravings that take over your day and increase that food noise that's kind of like a term that's thrown around quite a lot um then ultimately i think yeah it's important just to have some of those foods that you enjoy and not over restrict and yeah definitely experimenting with mouthfeel because food isn't just about the taste it's about how it feels as well you know like crunchy Some people crave something crunchy.

33:27So, yeah, it makes sense.

33:29Dr Karan: I always tell people, you know, I'm often asked in the context of like gastrointestinal anatomy and the like GI system. Where does digestion start? It starts in the brain, right? Like the moment you think about food, sometimes your salivary glands are releasing saliva. The enzyme secretion starts. the GI workforce, the GI system begins to start whirring into place as soon as you think about food and the anticipation of food. So that's such a huge component. You know, like it doesn't just start the moment you eat something, but actually even before that act as well. Yeah. And you know, I think that's why we get hungry at certain times a day, right?

34:10Our brains almost anticipates that it's something that has been learned.

34:14Dr Karan: You deal with patients who are on GLP-1s. It's a class of medication that has completely transformed our shopping behaviors, food habits, how we, you know, perceive certain things like, you know, it's, I guess, for many people, it's been transformational. But you know, it's changed culture as we know it, right? Are there any specific dietary recommendations you make for people who are about to start on GLP-1s who are on them right now? Yeah, I think it's really important, you know, they're about to start them. That's actually a really nice period of time where you can think, okay, what you can't really like like what sort of behaviors you have around food like your relationship with food the types of food you're choosing how often you're eating uh that's a really important thing to maybe do a bit of an audit on and think about okay what can i optimize before i start the medication to really get myself on the best foot when i do start because yeah the medication is fantastic i mean when it's used properly with the right people and it's been vetted by like a dietician a doctor you know a psychologist sometimes in some cases as well it can be really effective and life-changing you know it's not for everyone of course but yeah having that pre-period if you if you can get it to optimize some of those behaviors is great some of the things i'd be wanting to look at is okay how often are you eating right now because if there's someone that maybe just eats on the go it doesn't prepare lots of food or skips meals i'll be wanting to try and get more of a regular rhythm in place and to help them have more regular meals and then i'll be thinking about okay what types of foods are you eating if you're eating mainly sort of refined carbs you're probably not going to get enough of that protein and that's going to be really important for maintaining your muscle mass as you rapidly lose weight which will happen for most people but then also want to be thinking about those micronutrients as well and fiber because actually sometimes when people hyper focus on fiber especially with a small appetite where the volume of what they're eating is so low it might mean that they're unintentionally sort of missing out on fiber which isn't always in high protein foods right and then also those micronutrients as well so things like folate for example you find that really in plants and other micronutrients and vitamins and minerals as well like nuts and seeds you know thinking about magnesium selenium and all these other things that are really important for your overall health do you think it's worth someone doing a blood panel and maybe a micronutrient screen before they start on a glp1 Definitely.

36:27I mean, it often is something that is recommended to have a screening. But as comprehensive, I'm not sure if it includes every nutrient deficiency, but it is worth including, especially if you can get access to it to have a look at that. That's a good place to start.

36:42Dr Karan: When I used to perform major, you know, GI surgeries and abdominal surgeries, especially in high risk individuals, we did something called CPEX testing, you know, cardiopulmonary exercise testing before we do major surgery, where we identify high risk individuals and we look at their anaerobic threshold, their sort of lactate threshold to see, you know, how fit or frail they are for surgery. And if they're particularly frail, if they have certain anaerobic thresholds, we make them undergo this sort of pre-training for surgery or pre-habilitation. So if you're smoking, stop smoking. That's going to improve your lung capacity and your aerobic threshold, get you walking more, maybe lifting weights because the muscle is going to help you recover afterwards.

37:24Dr Karan: There's a whole bunch of things. And even dietary would get dieticians involved and psychologists if they have low mood, improve your mood before surgery can help with recovery. A bunch of things, right? to make them fitter for surgery. And that would significantly improve outcomes, reduce the risk of complications, speedier discharge from hospital. It was actually fantastic. And in Southampton, well, one of the leading centers, that's where we used to do it. And I always thought about the role of prehabilitation, but extended towards other things. If you're taking antibiotics, or if you know you're going to take antibiotics, start preparing your gut to be more resilient.

37:58Dr Karan: So even if it gets wiped out by the antibiotics, the baseline resilience is already higher so you can bounce back quicker similarly for glp1 medications it's going to have a gut impact to some degree maybe microbiome changes slowing of the gut all that kind of stuff but actually if you know a few weeks before can you start increasing your protein training more getting more fiber in all those sort of things and maybe that reduces the risk of side effects and the impact of glp1s when you start it i don't know i completely agree because you know a lot of people what the most common symptom is nausea especially in the first few weeks it might settle as your tolerance improves but when you have that it's gonna be really hard to think about okay i need to get enough either so you're having that habit in place already or there's like foods in your cupboard already will ultimately make it easier to get started so yeah really priming those like optimal behaviors that will help you feel better from a symptoms perspective but also those long-term outcomes think about bone and muscle which is so important is there i mean i guess you also have a lot of patients who start on a GLP-1, they have some desire to come off a GLP-1, they're scared of the weight bouncing back.

39:05Dr Karan: What can you do? What are some strategies that can act as a bridge, at least to some degree, that can at least maintain most of the weight loss that they've seen on a GLP-1 and they want to come off? Yeah, I think the first thing is mindset. You might think the first thing is about like, okay, food, you need to make sure you're eating on smaller plates or something boring like that. It's not. It's about mindset. Okay, you probably need to accept that when you come off, you're probably going to gain a bit of weight because you're eating more it's like inevitable so accepting that you're going to gain some weight is i think is an important first step and not catastrophizing and then thinking about okay how can i maintain my weight as best as possible so you might gain a few pounds whatever that's normal don't catastrophize it's about okay what can i do to try and minimize how much i gain because you are going to be eating more but there's so many benefits to be able to eating more as well you know socially there's benefits of that as well again you might be reducing your risk of things like nutrient deficiencies supporting your muscle health bone health etc so there are benefits to eating more a couple of pounds is okay it's just about okay what can i do to reduce that because if you catastrophize the likelihood is that you could spiral and you might make that weight loss worse so don't be hard on yourself practice some self-compassion and think about okay how can i continue doing what i was doing before now that the medication is not here because it wasn't just the medication doing the work it was you so give yourself you know some praise for all the habits that hopefully you would have already had in that time while you're on grp ones and then yeah how can i just continue that and it's just really the simple habit it's like eating regularly not letting yourself get too hungry where you might not make the best food choices you might overeat you know even things like meal prep can help you you know reduce those barriers to that doesn't have to be having really elegant meals throughout the week it could just be okay i'm going to make sure that i've got some chicken from the rotisserie in the fridge or i've got a tray bake of veg so i can just literally throw together i don't have to cut you know you can rip together some ingredients and they're like peppers you know and have that in the fridge just to quickly throw onto meals throughout the week it doesn't have to be really sophisticated stuff that takes a long time just these little micro habits that basically make behavior change easier and then make those other habits like maybe eating more calorie dense food for example and missing the gym making those habits sort of harder to actually do so you know that makes sense even if it's you know having accountability of like a gym buddy a pt a class that you regularly attend you know putting your gym care out as well because again it's not just about nutrition but all of these things that you can do to make staying the same really easier people coming off glp1s weight regain isn't a moral failure it is basic biology if something was suppressing your appetite and you remove that stimulus you're not going to have your appetite suppressed and you'll eat more and you'll gain weight and it's the same as no one's going to be chastised for having their blood pressure go up if they stop their blood pressure tablets right it's the same thing so you know i i guess that is the fundamental thing it's a chronic medication for most people will probably be on it lifelong if they want to maintain the weight loss and that's the thing i think that's a really interesting space i haven't seen any data on microdosing in the last few months at least but there's nothing really on that i know companies are sort of playing around with it especially the US so it'll be interesting to see if that is something that becomes the norm maybe we just end up microdosing it taking much smaller doses or taking it every other week for example yeah it'll be interesting to see what happens for that maintenance phase because maybe yeah it will be that people stay on it longer term just like people might stay on pain medication long term you know there was this you know kind of really scaremongering headline that I saw in the sun.

42:39Dr Karan: These were like fat jabs cause brain disease where there was this thing about this one woman who had Wernicke's encephalopathy and she was deficient of vitamin B1 thiamine because she was on a GLP-1 and they took that one case report and tarnished the entire GLP-1s with that and then people being fear-mongered into thinking that GLP-1s can cause this severe brain condition. which I think I find that a lot with GLP-1 medications these days you know they take one thing which is a small amount of truth in one situation and they apply that quite broadly which is detrimental overall to the field of metabolic health and people actually considering these medications to change their life.

43:22Yeah there is a lot of that and I just don't feel like you really get that with any other medication there just seems to be a lot of backlash for GLP-1s or fat jabs as i would never normally call them um but yeah so i agree with you that this is what happens i think we see that and not even in just medication but one small study will come out one small case report you know and then people run with it and say yeah you shouldn't be taking this it just sort of sensationalizes something that ultimately isn't really that relevant you know yes of course if you're not eating enough because of uh you know a medication that suppresses your appetite there is a risk of deficiency actually but there's a risk of deficiency with the general population as well and with any weight loss it's not unique to just grp1s you know bariatric surgery for example so it's about just making sure that you are eating a balanced enough diet and not letting these headlines scare you out of a treatment that ultimately could also be really you know significant in terms of health benefits for some people you know actually carrying excess weight living with obesity for a long period of time can impact things like your heart health liver health you know a lot of these people may already be living with conditions like type 2 diabetes so you've also got to weigh up the risks and cons and that's the same with any medication there's just a lot of stigma i think around taking glp1s yes um and i think it's just completely wrong you know we don't apply that stigma to people who are taking antibiotics you know it's uh

44:42Dr Karan: yeah it's a crazy yeah i wish more people had your very nuanced balanced takes on very complex topics whether it's glp1s or even supplement space as well and i think you know your books uh you know really does a good job of that as well how not to take supplements so Josie thank you so much no thank you it's been fun awesome