Episode 101:

Show Notes

  • Dr Rowena Field is physiotherapist who is also an expert in chronic pain - She uses a ketogenic diet to assist in treating chronic pain and has completed a groundbreaking study, researching chronic pain and nutrition, for her PHD with the University of Sydney.
  • Chronic pain - Pain that has been persisting for a period of time. The word “chronic” does not indicate the severity of the pain. 
  • Dr Field suffered from chronic back pain following pregnancy - She became frustrated when physiotherapy techniques did not relieve her pain and this inspired her to gain a greater understanding about chronic pain and the latest research on chronic pain.
  • A ketogenic diet can help - A ketogenic diet can help to naturally modulate some of the inflammatory molecules involved in chronic pain conditions. Dr Rowena Field no longer has any chronic pain and was able to run a half-marathon. 
  • Dr Field discovered that there was very little research available - The use of a ketogenic diet for pain management had never been properly researched before, so Rowena embarked on a PHD to thoroughly research the effects of diet on chronic pain. 
  • Research identified that people suffering from chronic pain are often metabolically unwell - They have an average of three comorbidities. Often they are overweight, pre-diabetic or have high blood pressure. The human body is a complex adaptive system and improving metabolic health can have a good flow on effect in pain management. 
  • Previous dietary trials of the ketogenic diet were focused on weight loss, but this research was focused on pain outcomes - a systematic review of previous trials showed improvement in inflammatory biomarkers and neurological outcomes, providing enough evidence to justify a clinical trial of the ketogenic diet on humans for pain management. The trial involved removing processed foods from both the control group and the test group’s diets, and incredibly both groups had a reduction in pain. The ketogenic diet group additionally had weight loss and reduced inflammatory biomarkers on blood testing. Interestingly, the ketogenic diet test group also noted improvements in depression and anxiety. 
  • Nutrition has far reaching effects on your physiology - We have known for a while that ketones modulate the excitability of the immune system, decreasing seizures and fits in epileptic patients.
  • Reducing the glucose load in the body decreases the glycation (damage) of proteins - This is protective for joints. Glycated proteins in the cartilage trigger an enzyme which causes cartilage degeneration. This is an important factor in the pathogenesis of  arthritis. Listen to episode 52, "What is the big deal with sugar?" to learn more about advanced glycation end products and why they are significant. https://www.rlmedicine.com/52
  •  The study provided patients with finger prick blood testing for home use -  This allowed them to reliably check if they were in ketosis. If they were not in ketosis they needed to decrease their carbohydrate intake further.
  • Many patients experienced an improvement of their pain outcomes - They had decreased pain and improved quality of life on the ketogenic diet after years of unsuccessful treatments for their chronic pain. 
  • Read the study here - https://www.futuremedicine.com/doi/abs/10.2217/pmt-2021-0084 
  • Dr Rowena Field’s STEPP program: Solutions, tools and education for persistent pain https://www.stepp.com.au/ 

Dr Rowena Field: 

PhD, M.Phty, B.App.Sc (phty), APAM, A.Nutr

Rowena is a physiotherapist with 30 years experience in both private practice and 8 years as a rehabilitation consultant for injured workers. She has worked extensively in occupational rehabilitation, assisting injured workers to return to their jobs.

Rowena has developed a professional interest in chronic pain management over the last few years and is keen to assist clients that historically have had limited options and may have been poorly managed. She completed a PhD with University of Sydney researching chronic pain and nutrition

Rowena is a member of the Australian Physiotherapy Association and Australian Pain Society

Rowena is also a photographer. She enjoys living in Jervis Bay with her husband, as well as her 3 adult daughters.

Episode 101:


Can diet help with chronic pain?

Dr Mary Barson: (0:11)  Hello, my lovely listeners. I'm Dr. Mary Barson.

Dr Lucy Burns: (0:15)  And I'm Dr. Lucy Burns. Welcome to this episode of Real Health and Weight Loss. Good morning, lovely listeners, it's Dr. Lucy here this morning on - well as I'm recording this, it is cold and rainy outside - but I suspect by the time it goes to air, it'll be beautiful and sunny. Dr. Mary is still on maternity leave, so we have a fabulous guest and we haven't covered this topic so I'm super excited. I'm going to introduce you to a beautiful woman called Dr Rowena Field and she is an expert in chronic pain and an expert in treating chronic pain with a ketogenic diet to the point where she's had papers published. So we've got a fabulous chat coming ahead. So stick around peeps. Rowena, welcome to the podcast.

Dr Rowena Field: (1:05) Thank you so much for having me.

Dr Lucy Burns: (1:08) So we were having a little chat off air to begin with, and your background is in physio, you're a physio. And I was curious to find out how you came across low carb or a ketogenic diet. So I'd love for you to share with our listeners how you stumbled into it.

Dr Rowena Field: (1:24) Yeah, sure. I guess, like anything, we all find these areas due to our own personal experience, often. So I was the typical chubby teenager that was always trying to go on some sort of diet to manage my weight. And given that I was growing up in the 80s that was all do lots of aerobics and eat low fat. And, , if you work really, really hard at doing that, you can sort of manage your weight, but it was always a struggle. And I guess, maybe 10 or 15 years ago, it just came across my radar, this idea of low carbohydrate and ketogenic diets, and it just made logical sense to me. So I guess I fell down that rabbit hole of finding out all about them and then I found that it worked really well for me. It was a great way to manage my weight without having to be really restrictive on calories or having to kill myself doing aerobics. Yeah, so I became interested in it and then I guess I started to take a bit more of a deeper dive into the science that sits behind it, to understand that a little bit better as well.

Dr Lucy Burns: (2:30)  Yes, I love that. And I think so many health professionals do that. They stumble across it for their own curiosity and usually applying to their own needs, and then go, “Oh, this thing works! Yeah, I might need to find out a little bit more”. So I love that. And I love that not only have you found out a little bit more, you're actually now a leader and other people will be finding out a bit more from you, which is fantastic. So you found low carb/keto. And then what happened?

Dr Rowena Field: (2:56) Well, I guess it was sort of happening at the same time as my other area of interest, which is chronic pain management. And again, exactly the same story. Because I had chronic pain, I had to do a little bit more research into trying to manage my own problem. And it was one of those things where I thought I knew at all about pain management, being a physio. I learned it all at uni, obviously. And I've been a clinician in private practice for probably 10 years or so by that point. And I ended up developing chronic back pain when I was pregnant with my second child, which sort of came and went, in between that and my third child, but by the time I was pregnant, for the third time, I had this terrible back pain that I assumed would go away once I wasn't pregnant anymore. But unfortunately, it didn’t. It just hung around and got worse afterwards. I went to see all the “cool kids'' in physio land. All the people that were doing all the trendy courses to try and fix my back and it just didn't matter who I saw or what I tried, nothing seemed to fix my back problem. So I started to honestly believe that I was a bit of a unicorn and there was something different about my back and I'd reflect back on all the clients that I’d had. They’d come in and they’d tell me that their back pain was worse. And I just look at them and say, in my head I'm thinking, “You just didn't do what I told you to do”. And then when I was put in that situation and I realised all these things that I'm telling everybody to do, it doesn't work for me either. Something is just not right here.

(4:21) So I went down that rabbit hole a little bit trying to find out, “What is it that I don't know and I don't understand about chronic pain?” And I guess I was lucky in that one of the one of the guru's or the cool kids in the space at that moment was a guy that I went through uni with. So that just made me interested to find out what he was researching and what he was doing. And I came to understand that most of what I learned at uni about chronic pain wasn't really what the latest research was saying and that it had a whole heap more to do with this whole idea of whether my whether my brain was perceiving that I was safe or was I not safe and if I wasn't safe in what I'm doing then protection was required. Pain is the obvious thing to slap you up the side of the head and make you take notice and change what you're doing. And we always assume with a chronic pain problem, there's something about the structure, it's the muscle, or it's the joint, or it's that thing that's driving the problem. Whereas with chronic pain, there's a whole lot more that's actually driving that problem. And I had no idea about any of that stuff.

(5:20) I ended up in a lovely neurosurgeon’s office who had told me that the only way to fix my pain was to have two of my discs replaced. And I guess, again, luckily, for me, I wasn't in a health fund at the time. And so he said, Go away, spend a year until you're eligible for it, come back, and we'll do it. And it was in that year that I'd started to take a little bit more interest in the research behind it, and try and understand it for myself. And I guess, I never had the surgery done and I instead changed tack and started to treat my chronic pain differently and learn differently about how I needed to manage that and eventually got to the point where I don't have any chronic pain now. I even ran a half marathon not that long ago. Well, it’d be getting a bit longer now. But it just goes to show that even though we think the structure might not look pretty on a CAT scan, or we automatically assume that that's the thing, that's the problem. When in my case, it definitely wasn't, like my I'm sure my MRI scan doesn't look any prettier than what it did the day the surgeon said to me, “Well, you need to have those two discs whipped out”, but yet I have no pain now. So our understanding has really developed a long way now to realise that there's so much more that goes into pain management. And, and I guess to sort of join those two stories together, it was when I was looking at what's involved in chronic pain, and we're trying to reduce inflammation, and we're trying to find medications that will target inflammatory markers, and those sorts of things. And that's where all the research was heading. 

(6:51) I'd sit in conferences for chronic pain. And they'd be talking about all these fancy inflammatory molecules, and we've got this drug or this other drug that's trying to target those things. And I'd be thinking, “Oh, hang on a minute! I remember listening to a lecture about a keto diet back over here that I was also interested in and that was saying that's a way that you can naturally modulate some of those inflammatory molecules. You guys should really be talking to each other.” And so I started looking a little bit harder to see, okay, well, where's all the evidence about doing dietary intervention for chronic pain, and funnily enough, there is not very much at all out there. And there's virtually nothing about low carb or ketogenic diets for chronic pain. So hence, I fell into a PhD. And that's what I did my research topic on. I was looking at ketogenic diets for chronic pain management.

Dr Lucy Burns: (7:40)  I just love that. I love it. And I think one of the things that I'm taking from that is that medicine, often users like to look at one problem and then just extrapolate the solution as another problem. So it's looking at how to treat acute pain. “And we will treat that chronic pain the same because surely…” Chronic, so for our lovely listeners, chronic just means ongoing, like it's chronicity related to time - doesn't mean severity, it's just about the duration of your pain - and acute means happening at the moment. And so we were treating people with long term pain in exactly the same way as acute pain. And it's the same really, when we look at how to manage people who are storing excess fat. The idea was that, “Well, they should just do the same as what you do to prevent obesity, which is diet and exercise. It's exactly the same”. So again, it's the same thing, what you use to treat obesity is different to what you do to prevent it. But we didn't do that. We just extrapolated the same information. So yeah, I love that. So tell me then. So a PhD, that's quite an undertaking.

Dr Rowena Field: (8:54)  It's one of those things that seems like a good idea at the time, when you're in the middle of it, you're tearing your hair out, going “Why did I do this!! But no, honestly, it was great. I loved doing it.

Dr Lucy Burns: (9:01)  And I think the thing is too, in this space we are looking for evidence, because for a lot of the time, you have an idea, an hypothesis.  I guess this is how research works: You have an hypothesis and you want to check that it works. And for a lot of particularly nutritional information, people will take their hypothesis and turn that into evidence without actually having any research to back it up. It just sounds like a good idea, so therefore… and then it just becomes sort of spread on and that's suddenly the truth. So can you tell us a bit about your research? Tell me. I'm so fascinated to know about it.

Dr Rowena Field: (9:34)  Yes, I guess when you're doing a PhD, you've got to build the story. So you might have this idea about what you want your big cornerstone project to be, but you have to do lots of little steps along the way to build the evidence base, to support why you're looking at the thing that you're looking at. And so my starting point in the PhD was to do a bit of a cross sectional study of a whole stack of people with chronic pain and to actually find out whether they thought their diet was important or not. Whether the thought had had anything to do with their chronic pain. And I thought that was an interesting thing to look at. Because when you look at all the statistics from - so we've got a database called the epoch database in Australia and New Zealand, which is all of the tertiary chronic pain institutions, they keep all their data about all the people that go through and I think we've got, I can't remember, I think it's like thirty odd thousand people a year go through these chronic pain programs. And if you look at that cohort of people and how metabolically well they are, they all have an average of three comorbidities. So when we're talking about people with chronic pain, they're overweight, or they're pre diabetic, or their blood pressure's up, or there's some sort of metabolic thing going on, generally speaking, as well. But yet, we sort of ignore that whole metabolic side to chronic pain. What we do is look at, “What medication we are going to give?”. Or, “What are we going to do for their pain problem in their shoulder?” We're not standing back and saying, “Oh, hang on a minute, this person is overweight, they've got  all these other things going on”. 

(11:05) When we consider that we're a complex adaptive system, you can't just pull their shoulder pain out and put it in one bucket and put all their metabolic health in a different bucket. We're all one person, that's this complex system, that's all integrated in a way that people don't even comprehend. And so I guess that was the starting point to say, ‘Okay, well diet is actually important for that reason, because they're all metabolically unwell”. And also, because all these people were saying to me, “Oh, yeah, my diet’s fabulous!” But when we looked at it their diets really weren’t fabulous at all.

(11:34)  Their average BMI was 31, or something like that. So there are lots of good reasons why just improving somebody's metabolic health should have a good flow on effect, to pain management as well. And it wasn't something that was really being even considered. So that was sort of the starting point. And I guess, my bias, then going into this was saying, “Well, okay, the thing that I want to have a look at going into this is a low carbohydrate or a ketogenic diet.” So then you have to build the evidence as to mechanistically, how is it plausible that this diet would actually affect pain outcomes? Because we're all very used to looking at dietary trials and the thing that they're looking at is weight loss. But we weren't so interested in weight loss we're interested in, “Does this actually help the person's pain?” And so then we went back, and we did a big, huge systematic review, where we pulled up all of the literature, where somebody was put on a diet for a chronic pain outcome. And so we found, I think, there's about 43, or 44 studies that have been done. And we're specifically looking at only whole food diets. So there's lots out there where people are just given a supplement or something like that, but we were actually looking at if we actually change their diet properly, what ones have we looked at that could potentially have pain outcomes? And so out of all of those, there was only one low carbohydrate arm in all of that, but all the rest of it, there was a whole smattering of different types of diets. Everything from your vegan vegetarians to the mediterraneans to your gluten free, there's a whole heap of different things in there. And when we did a meta analysis, which is just basically putting all of the research together, so we did like a mega study, essentially, and put it all together and trying to find out, you know what, okay, out of all of those, which one's going to be the best for for pain outcomes. And basically, what that showed was that they all work a little bit

Dr Lucy Burns: (13:27)  Right. Okay.

Dr Rowena Field: (13:29) Which is not really helpful when you're trying to figure out which diet’s the best and so we sort of scratched our heads for a little while about that and thought, “Okay, well, what we're actually doing when we put somebody on a whole food diet, is that we are, by default, improving the quality of their diet, we're pulling out the processed foods, and we're getting them to cook a bit more from home and all those sorts of things.” So what we took away from that, was that, okay, your diet does do something. And obviously a diet that improves the quality is important in all of this. And so then we then moved on, and I did two further scoping reviews to look at the ketogenic diet and look at it mechanistically. So the first review was looking at all of the animal and preclinical research to try and come up with what mechanisms are involved in the diet and how they would be related to chronic pain. There's a whole heap of things in there that are potentially ways that pain might be improved. They include helping to desensitise the nervous system. They help mitochondrial function. There are all sorts of different, possible or plausible ways that pain could be improved by putting them on a ketogenic diet based on mouse model stuff. So then we went on and looked at actual human trials that had used a ketogenic diet. And again, we found that there were lots of, so we looked specifically as to whether there were improvements in neurological function or inflammatory markers and both of those significantly improved in all of the ketogenic trials, and there were quite a lot of them. I'm just trying to remember off the top of my head, how many?  Where are we? There was? I guess that's one of the things that often gets said about ketogenic diets as well. “There's no real evidence behind it.” But we found 846 clinical trials. 846!

Dr Lucy Burns: (15:16)  Oh my God!

Dr Rowena Field: (15:17)  And these were all low carb, so less than 130 grams of carbohydrate per day and lasted for longer than two weeks. So we're not just talking about the little piddly trials, but actual proper dietary changes. 846 trials, 64 trials that had neurological outcomes, and 83% showed an improvement, and 63 trials with inflammatory biomarkers, of which 71% showed reduced inflammation. So there is quite a lot of good supporting evidence out there as to why a ketogenic diet might actually improve pain outcomes. And so, doing all of that stuff that we've talked about that was sort of setting the scene to say, okay, there's good reasons. We're not just making up a diet for the sake of it - which is what we found when we look back at the systematic review. When we looked at all the ones that had been done, basically, it was just researchers picking their favourite diet and doing it just for the heck of it, because that's what they thought was the best diet and not because there was any real rationale behind that diet actually changing something to do with the nervous system or something about chronic pain. So we've gone along, and we'd established a really good reason as to physiologically why the nervous system should improve if you change the diet. And then we went and did the clinical trial to show that so we just did a small pilot trial where we had about 24 people that went through and we did this trial in a way to try and minimise the criticisms around dietary trials. So firstly, we did it as a randomised control trial. But what we did was a three week run in for everybody to begin with. So for the first three weeks, everybody had to just remove the processed foods from the diet. So we cleaned up everybody's diet, we weren't trying to compare a ketogenic diet to a standard Australian diet, we had everybody at “baseline”, inverted commas, a good diet of whole foods. And then at the three week mark, we randomised them to either just continue doing that diet, or to reduce the carbohydrates down to less than 50 grams per day. And so the outcome of that was interesting in that both groups did get an improvement, like a significant reduction in pain. And I think that's an important thing to point out. Because as much as I love the ketogenic diet, you often get patients that that's just not doable, like, it's just all too hard to be thinking about, all that sort of stuff. And so if all we're doing is encouraging people to pull the processed foods out of their diet and eat whole real food, then in all likelihood, they will get some sort of pain benefit from doing that. But when we look at the ketogenic diet, they got a bit greater pain improvement, but they also had reduced inflammatory biomarkers on blood testing, which the other group didn't have, they also lost significant weight that the other group didn't lose. And they also had improvements on their depression and anxiety scores that the other group didn't have, either. So there's all these other added benefits around reducing the carbohydrate load that, if you can sort of get people to buy in initially with doing some dietary change, and they start to feel a little bit better for doing that. Because, actually, if we take this a little bit further, and actually reduce your carbohydrates down, there's a lot of reasons why you might get further benefits from doing that.

Dr Lucy Burns: (18:30) I love that. So Mary and I have this fancy word that I call pleiotropic, which means one intervention has multiple benefits. And , you've just described that exact thing. So the first step, real food, and then the second step, low carb. And then by doing that you will have multiple benefits, apart from weight loss, but pain, and mood. And it's so interesting, the mood thing, because again, it makes it makes sense, doesn't it? Our brain is just a giant piece of neurological tissue. And we know that all the original studies on on the ketogenic diet were to look at treatment for intractable epilepsy, which is a brain disorder. And so yeah, it's just, it kind of makes sense, doesn't it? And yet, for so many people, they're blinkered about that. And there's a particular doctor in the UK who I like his style, and I like his thoughts, but he has a book that I don't like called “Food is not Medicine”. And I kind of actually just completely disagree with that.

Dr Rowena Field: (19:39) Yeah, I think we totally underestimate how changing your nutrition and how your eating can affect your physiology and really, it's quite amazing when you think about it. As you're saying, the ketogenic diet has been used for a long time for epilepsy and it's just amazing that having ketones present in the system can modulate the excitability within the nervous system, but we often think about it in terms of epilepsy, which is, I guess, a nervous system that's getting so excitable that we have a fit or a seizure. But the way that ketones seem to work is they tend to modulate it back into that sort of homeostatic level, because that's actually at the moment, we're looking at getting a big wad of funding, hopefully to do a clinical trial, looking at using the ketogenic diet for narcolepsy, which is sort of like the opposite end of the spectrum. So you've got a nervous system where the excitability is getting depressed to the point where the person falls asleep, obviously. So there's something about ketones that just seem to bring it back into that Goldilocks zone in the middle, whether it be too high or too low, it seems to bring it back, into an appropriate zone for a functional nervous system. So that's quite amazing when you think that how you eat can modulate your brain activity to that extent.

Dr Lucy Burns: (20:59)  Ah, totally! And I think, for lots of us who, I use the woodshed analogy, which is how we're storing all our fat. And once we lower the insulin levels and open your shed, you have this beautiful source of ketones that you've been lugging around with you for years. It's so, I think that's why sometimes people really love that the ketogenic aspect of a low carb diet is because they genuinely feel better.

Dr Rowena Field: (21:27)  I think the other interesting thing too, that came out of the research, we talk about a lot of our ketones, because that's where we get the name ketogenic diet from, but ketones are only part of that story. When we looked at the ketone levels of the people in the trial they didn't get up that much. I think the average ketone levels were only like 0.4 or 0.5 or something like that. It wasn't really big numbers. And, well, I guess we were expecting it to be a lot higher than that, because we're really thinking “Oh it’s the ketones that are doing all these magical, amazing things that they can do”. But you've also got to think about the flip side of what else you do and you're also reducing your glucose load. So even though it might not specifically be the action of the ketones, there's all these other actions that occur, just because you've got less glucose volatility. And so not only do you have less insulin, like you were talking about before, we're managing insulin. But the problem with having too much glucose in the system, as you would know, is that glucose is a bit of a naughty molecule and likes to stick itself to proteins, and then those proteins don't work properly. And that not only occurs in your haemoglobin that we're all used to talking about with diabetics, but it attaches itself to all the proteins in your tendons and your ligaments, and all these sorts of things as well. And so there's then a degradation of the quality of those tissues, which is obviously important when we're thinking about chronic pain and the development of pain problems. And those glycated, we call them AGEs, advanced glycation end products, they actually get into the cartilage and they trigger an enzyme, which causes cartilage degeneration. And so, for so long, we've thought about arthritis being a very much a wear and tear problem. And it's just because you've got too much loading on the joint, it's all that mechanical friction that's just wearing out the cartilage. Whereas now we're starting to say, well hang on a minute, if we put people with arthritis on low carbohydrate diets, their pain actually improves, but the prettiness of their scans or their X rays possibly doesn't change much at all. And that's then starting to come back to this idea. Well, this glucose that's floating around and doing things that it shouldn't be doing is actually triggering deterioration within the cartilage. So if you don't want your cartilages to wear out in your knees, and everywhere else, well don't have a diet that's making your sugar fluctuate all over the place. And, and we're not teaching people that sort of thing.

Dr Lucy Burns: (23:41) No, not at all. And it's fascinating. I love the whole the advanced glycosylated end product discussions, and we did do a podcast earlier on that which I'll link in the show notes, but it also extrapolates that to skin and people are wondering why their skin is ageing, and a lot of people think it's because they've been out in the sun and that does have an effect, as does smoking, but so does this glucose degrade your collagen. So it's the same, it's exactly again another lovely pleiotropic effect by just…  So, what I love is that these discussions are not about weight. Like of course listeners, you know that Mary and I, we talk to people about weight management and often we try to use losing weight as ‘the hook’, but the thing about living a low carb lifestyle is that the weight almost becomes secondary. Because you improve your pain levels, you improve your inflammatory load, you get to be able to move more easily. So you therefore can do more walking, which makes you feel better, which also helps your mood and it just interrupts that whole cycle of chronic disease or the or the effects of chronic disease.

Dr Rowena Field: (25:00)  And I think that's one of the important things when we're thinking about using diet for pain management as well and particularly with the type of clients that I work with that have had chronic pain for a long period of time. They come into us very much feeling like they're in the bottom of a big black hole at this point, because they've seen every doctor, they've had every intervention done, they've tried every medication, and nothing seems to work and nothing helps or makes them better. And they feel like they've got no control over any of this stuff, they've just jumped through all the hoops and nothing has helped. Whereas if you can give them something like a diet where there's an objective thing that you can measure - you can measure whether you're actually producing ketones - they can follow the dietary change. And not only might they lose a little bit of weight, start to feel a little less foggy, start to improve and their pain improves, we start to get a real good flow on effect from that. And it's something that they can really take control over and feel like they're getting some control back in their life again, which is really lacking with chronic pain, I think.

Dr Lucy Burns: (25:55)  Absolutely. Hey, tell me, did you come across any studies looking at exogenous ketones and their effect?

Dr Rowena Field: (26:03) There's lots and lots of that out there, but we were only looking at endogenous ketones, so that sort of got screened to the side. But I think, there's quite a lot of research in that area, obviously, within patient populations where it's more difficult to implement a ketogenic diet. So if we're thinking about people with Parkinson's, and Alzheimer's, and all those sorts of ones that aren't really going to be able to necessarily comprehend or implement a ketogenic diet, then using exogenous ketones, I think has a lot of scope for treatment options and down the tracks, I think that'll be a really exciting space. And I'm really interested to see what would happen from a chronic pain perspective with that, too, because it just may be another treatment option, but that study certainly hasn't been done.

Dr Lucy Burns: (26:46)  Yeah, yeah, no, that'd be interesting. And again, I'm trying to sort of look at it thinking, well, if we're looking at most of these people having metabolic disease as perhaps one of the underpinning reasons they've developed chronic pain, then ideally, we want to fix the metabolic problem. And so sometimes taking exogenous ketones doesn't actually address that. You can’t just take a bunch of ketones and then go and eat a pie and wonder why it's not working. I just find it so interesting that there are so many tools out there and used appropriately they can be beneficial, but they're usually not a replacement for just this bog standard, unexciting, but incredibly important advice, to eat real food.

Dr Rowena Field: (27:33)  So it's not really rocket science, is it?

Dr Lucy Burns: (27:40) No, but I think for a lot of us, we've been conditioned to believe that it's hard, that it's hard to eat real food, that it's much easier to eat processed food. And I mean, I often say to people, we will, of course, you believe that, because you've been marketed, that's been marketed to you for your whole life. Yeah, maybe 40-50 years, you've been told that having processed food is a great option, because it's convenient. And you're too busy doing other important things. Whereas actually, if you flip that and go, “Well, actually eating real food has such enormous benefits across all of your bodily systems”, that can be the number one priority, because then you won't need to be going and wasting your time at the doctor's getting scans for your sore knees. So, I think I was reading a quote somewhere that  ‘Intensive care now saves you from Intensive Care later’. 

Dr Rowena Field: (28:30) Yeah. 

Dr Lucy Burns: (28:31) Yeah. So Rowena, do you, in your practice, do you talk to people about low carb lifestyles? Or how do you do it?

Dr Rowena Field: (28:39)  Yeah, so I work in a private practice with a psychologist and we run a pain management program. And so that involves having several education sessions with myself and several with the psychologist, and a lot of it is around the neuroscience education that I briefly mentioned a little bit before, but it also includes looking at lifestyle stuff as well. So I get a chance to launch into my low carb, at times, so most people and probably our clientele are a little bit different in that by the time they’ve got to us, they’ve have sort of run out of options, pretty much and so they're prepared to try anything that I that I say, but most of them are open to the idea of of doing a dietary intervention. And I approach it in sort of two steps, a bit like how I did in my PhD. I start with “Okay, let's just start by removing the ultra processed food from the diet. Let's just start there.” And we'll give them a few weeks of just doing that. And if they're still walking with me at that point, then we start to talk about the added benefits that could happen if we actually trialled a ketogenic diet, and I try and encourage them to, if you're going to do this, you can't sort of half arse it. You've got to really do it properly for six weeks so that you can actually tell how much this is going to change your pain outcomes, because if you do it for a day, and then you have a day off and you do it for a couple of days, and then you get a maccas, you’re really not going to be able to tell. So let's commit to doing this properly. And let's see how we go. And we'll measure ketone levels and that sort of stuff with them as well, so that they can see how they're going and I find that's quite a good feedback mechanism to help people understand whether they've actually reduced their carbohydrate level enough. And that's what we did in our clinical trial. We gave them one of the finger prick testers where they can measure their glucose and their ketones. Because by definition, if they're not getting any ketones present, well they haven't lowered their carbohydrates enough. And so, it's a nice way rather than having to count calories, or carbs, or any of that sort of stuff. All we're doing is saying, “Hey, yeah, well, you've got some ketones there. You're going, okay. How do you feel?” And so that's a nice way of helping people just to wrap their head around what sort of things they need to, reduce out of their diet, and then go from there. But we've had some really good results with people doing the diet in the program and certainly the clinical trial, as in any trial, you're gonna get people that do the diet and don't do the diet, but the ones that actually did it properly in the trial, were quite, there were some really quite remarkable results. I had one lady that had chronic plantar fasciitis in her foot for, I think it was going on for years at that point in time, and she had all the orthotics done and had done everything, had all the cortisone injections in it, nothing had fixed it. And within three weeks of doing the ketogenic diet, she had zero pain, there was from a seven out of 10, down to zero. And when we checked with her three months down the track, she was still zero out of 10 pain. So I think particularly with those inflammatory type things, there's a lot of benefit in doing keto. There was another lady that had a back problem that she'd had for years. And it was funny because when she got randomised into the group that was having to do the ketogenic diet, she said “Oh Rowena, I just don't want to do it.” And here we go, here's a dropout coming now. So sort of cajoled her along, “Hey, this will be okay, I'll help you as much as possible.” And then she came back a couple of weeks later crying, she said, “If you had told me how much my pain would decrease, just from two weeks of doing this - why has nobody ever told me that changing my diet could affect my pain, like this?”  And they're the sort of ones where, when that sort of thing happens you think, even if it doesn't work for everybody, that people that it does work with, it really does change the quality of their life, and it really improves their pain outcomes.

Dr Lucy Burns: (32:17)  Ah, God, what a wonderful story and how satisfying for you as a practitioner to be able to see that change in that person's quality of life.

Dr Rowena Field: (32:27)  It is. It makes it worthwhile.

Dr Lucy Burns: (32:30) Yeah, absolutely. Mary and I always say that we've got, sometimes I think I've got the best job in the world, because I can see, you know I don't have a crystal ball, but I can see how their life is likely to end up if they don't change and the potential of where it could go. So I call it, ‘You can go down to chronic disease hell, if you like, or you can go over to healthy life nirvana’.

Dr Rowena Field: (32:52) That's right, you just gotta get them to buy into it. And then once they start to get just a little bit of success, then you get that roll on effect until they can see that they're getting somewhere with it. And that's what we see with the pain stuff. You just need a little bit of light at the end of the tunnel, a little bit of improvement, a little bit more movement, and then, they’re sold then. 

Dr Lucy Burns: (33:10)  Absolutely. Well, I suspect we will have inspired some people today to give the low carb and particularly the ketogenic diet a go because, chronic pain as we know is very prevalent in our society and lovely listeners the benefits - well you've got nothing to lose - like you have nothing to lose except your pain, which would be awesome. Rowena, darling, Thank you. Thank you so much for your time today. That was a fantastic chat. And for any of you people who might be coming to Low Carb Down Under, Rowena is coming, as am I and yeah, we would love to talk to anybody about pain, low carb, anything. I love it because you get to talk about your passion, kind of and people are happy to listen to you.

Dr Rowena Field: (33:54)  Yeah, that's right. It's not like your family which just glazes over when you start talking.

Dr Lucy Burns: (34:00) Oh, that's wonderful. All right, lovely listeners. I'll catch you next week. Bye for now.

Dr Lucy Burns: (34:10)  So my lovely listeners that ends this episode of Real Health and Weight Loss. I'm Dr. Lucy Burns.

Dr Mary Barson: (34:18) And I'm Dr. Mary Barson. We’re from Real Life Medicine. To contact us, please visit https://www.rlmedicine.com.

Dr Lucy Burns: (34:29) And until next time, thanks for listening. The information shared on the Real Health and Weight Loss podcast, including show notes and links provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns. 

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