All Things Inflammation with Lisa Costa-Bir and Dr. Tim Crowe

All Things Inflammation with Lisa Costa-Bir and Dr. Tim Crowe

Dr. Tim Crowe joins our Ambassador Lisa Costa-Bir to dig deep into the various phases of inflammation, what they look like, how to identify degrees of inflammation, and most importantly what we can do about it.

Together, Dr. Tim and Lisa identify the differences between acute and chronic inflammation, and unpack the important concept of resolution of inflammation. There’s interesting discussion around the interconnected systems of the HPA axis, the gut-mind connection, and various lifestyle factors that can trigger and feed low grade inflammation, as well as the various everyday factors that can contribute to chronic inflammation leading to disease.

Finally, they discuss the 'Holy Trinity' of managing chronic inflammation – diet, exercise and lifestyle, including therapeutic practices like forest bathing, colourful food choices (especially those high in anthocyanins), including healthy fats, manageable exercise routines and booking in for that sauna.

Covered in this episode

[00:44] Welcoming Dr. Tim Crowe
[01:42] Is inflammation alway a bad thing?
[03:37] Determining the presence of chronic inflammation
[08:31] Inflammation and the microbiome
[10:08] The impacts of stress and loneliness on inflammation
[12:51] Sleep and inflammation
[13:54] Conditions related to chronic inflammation
[14:51] Reducing vs resolving inflammation
[16:29] Specialised pro-resolving mediators (SPMs) to resolve inflammation
[18:55] Lifestyle strategies to combat inflammation: prebiotic fibre and physical activity
[22:32] Mechanisms of how things like exercise and saunas help reduce inflammation
[25:48] Green spaces alter the gut microbiota
[28:40] Food, the anti-inflammatory diet
[31:50] Supplementation to consider to reduce and resolve inflammation
[35:48] Foods high in polyphenols
[37:05] Summarising today’s key points, thanking Tim and closing remarks

Key takeaways

Acute inflammation - the type you see and feel - is a necessary process that serves as protection for the body.
Understanding reducing inflammation VS resolving inflammation is important for long term patient care. The analogy given is a raging fire that when contained to a barrel, the fire reduces but continues to smoulder. However, pouring water over the fire extinguishes the flames, putting the fire out and resolving the issue.
Novel metabolic pathways for resolving inflammation include metabolities of omega-3’s and omega-6’s where the metabolism continues on from EPA/DHA and AA respectively. We’re all able to produce these metabolites endogenously while in a healthy state but certain risk factors and conditions detract from our ability to make adequate amounts.
Pathology tests to help measure and assess inflammation include:
- CRP: for measuring severe levels of acute inflammation.
- hs CRP: useful for sub-clinical inflammation, the more sinister type. Has a higher sensitivity so can be a useful analyte for patient presenting with signs and symptoms of chronic inflammation or “sickness behaviours” and tracking for improvements
Connections between stress on the HPA axis, the gut-mind connection, and inputs to the vagus nerve cannot be discounted as this contributes to overall inflammation levels. Loneliness and isolation are also shown to increase inflammation.
Sleep issues are well researched for their role in triggering inflammation. Lack of sleep also increases risk of poor dietary choices leading to metabolic issues and gut dysbiosis which further increases inflammatory processes.
Physical activity – ANY physical activity – is better than being sedentary. Tim suggests to what works, do what you enjoy, and do what you can do regularly! It all adds up!
Taking supplemental antioxidants (not including food sources) can blunt the beneficial adaptation response we typically obtain from exercise.
Heat shock proteins can be activated by exercise and visiting the sauna, which can induce an anti inflammatory effect. Saunas can help lower the inflammatory marker CRP due to the mild exposure to heat stress triggering anti inflammatory mediators. This also forms the basis of cold therapies ie. Ice-baths
Getting outside into nature can help to reduce stress – this means getting into any green spaces. Going to a local park, a national park, and even your back yard or garden can all bring health benefits. Studies show that conifer forests are likely to have increased health benefits from volatile chemicals like terpenes given off by the trees.
For a super boost of anti inflammatory support consider supplementary curcumin (not turmeric), high dose EPA/DHA and SPMs. Polyphenols of focus are anthocyanins found in berries (any berries will do!). These reach the colon to be metabolised by the microbiome into their beneficial compounds.

Resources discussed and further reading

Dr. Tim Crowe

Dr. Tim's website: Thinking Nutrition

Thinking Nutrition Podcast

Book: Understanding Nutrition

Dr. Tim's research

Connect with Dr. Tim: Instagram | Facebook | Twitter

High senstivity CRP

Polyphenols

Article: The microbiota - polyphenol interplay in neurodegenerative disease (FX Medicine, 2019)

Transcript

Lisa: Hi. I'm Lisa Costa Bir, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine.

FX Medicine acknowledges the traditional custodians of country throughout Australia, where we live and work, and their connections to land, sea, and community. We pay our respect to their elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Joining us on the line today to talk all things inflammation is Dr. Tim Crowe. Tim is a research scientist, a dietician, co-author of Understanding Nutrition, now in its fifth edition, and he also hosts his own podcast, Thinking Nutrition.

Hi, Tim. Welcome to FX Medicine, and thanks so much for being with us today.

Tim: Lisa, great. Thank you very much. It's great to speak to you and be invited on the podcast, particularly about this very relevant and wide-ranging topic of inflammation.

Lisa: Absolutely. So, let's chat inflammation. I'll start off with just setting the scene. So, low-grade chronic inflammation is at the heart of most of the conditions that we see in clinic, and it's estimated that one in three Australians has a chronic inflammatory disease. So, I'm very excited to hear your insights today, Tim, particularly on how to resolve chronic inflammation as it can be such a complex area.

So, can you start by telling us a little bit more about inflammation, and is inflammation necessarily a bad thing?

Tim: Yes, so you certainly hit the nail on the head that inflammation is forefront in the public's and clinicians' mind. It's really underpinning many of the chronic diseases we are faced with in Western countries like Australia. So, you think of it as if it’s a really bad thing, but it's actually a good thing as well. We actually need inflammation. It's part of our body's immune system. If you cut your hand, if you fall over and graze your knee, that redness and pain that you see and feel is acute inflammation. That's part of the body's way it deals with the acute injury. And then, over time, that inflammation is suppressed and then the body regenerates and heals.

So, inflammation's critically important. It's not bad, it's part of our body's natural defence system. It's when it's chronic that that's the problem. If you think about, if it's a fire that is not put out, that fire keeps doing a lot of damage. So, inflammation is great short-term because of the changes it causes, but long term it's very harmful for our health.

So, inflammation you can see and feel is generally going to be acute inflammation, but the bad sort is the chronic inflammation, which you're really unlikely to know that you've got it. There's ways that you could probably have an indication, but it underpins many of our diseases, and it's more systemic. So, that's the differences between them. So, it's not that inflammation is bad, it's too much of it for too long. That's the big problem.

Lisa: Okay. So, you said that when we have acute inflammation, we can typically see it. Totally agree.

Tim: Yes.

Lisa: I fell down... Actually, I went rock climbing, fell off the rock, had a glass bottle in my hand, had shardes of glass all through my hand, and it was very apparent the acute inflammation, redness, swelling, oedema.
But what happens internally when you've got chronic inflammation because, as you said, sometimes we can't actually see that in the same way as acute inflammation. So, say someone has an autoimmune condition...

Tim: Yes, correct.

Lisa: ...or atherosclerosis, what's actually happening internally with chronic inflammation?

Tim: Okay. So, what's happening is there's a whole lot of systems involved. One of them is one of the key immune cells, white blood cells, those macrophages. So, what happens is they will go to a site of infection or damage, and they will actually then initiate cascades with other immune cells to release things called cytokines, which are signalling molecules that really mediate a lot of the inflammatory process.

That can actually be systemic throughout the body if there is some form of injury or infection all throughout the body, and you necessarily won't know that's happening directly. The presence of disease may indicate it, but there are ways we can actually measure this by a blood test. And one of them is the blood test for CRP, C-reactive protein, which is a really nice mark of inflammation.

And there's two different types. There's really severe acute inflammation. So, think really advanced cancer where the body is breaking down, you could have CRP levels that are in hundreds of milligrams per decilitre. Where it's very subclinical information, we can use another test called hs-CRP, which is a high-sensitivity CRP. That may not be up to really high levels, but it's enough to show that the CRP levels are higher than normal. And CRP is a marker of the inflammatory response. So, there are ways we can measure it by a blood test, and it's a very robust marker of overall inflammation.

Lisa: Okay. So, sometimes in clinic, when I've got someone with an autoimmune condition, for example, and I can tell they're super inflamed, it might not be something like rheumatoid arthritis, where I think I would see those elevated levels of CRP. But sometimes with Hashimotos, you can tell that there's inflammation but it's not necessarily showing up with high CRP.

So, do you think it would be correct to say that patients don't necessarily have to have elevated levels of CRP and ESR on their bloods for there to be inflammation present?

Tim: That's correct, but it also depends what test is done. Most of the time, it's just called CRP which is more of a bigger measure of inflammation hence this other test called hs-CRP, which is really designed to just pick up levels of inflammation still in the more reference range of 0.5 to 10 milligrams per litre. That's not as common a test, but that's a good predictor of things like cardiovascular disease. So, if those tests are available, it's useful. But you're very right, you know, really overt information. You'll just see it in a regular CRP test. But for just very low subclinical, that test won't show it but there'd be signs and indications it could be present in the person as well.

So, part of it is clinical judgment as well. When you're doing history, are there potential other things ticking off boxes related to lifestyle factors that could exacerbate that? And we'll get into that fairly shortly about the big lifestyle factors that can affect inflammation.

Lisa: Yes, that's a really interesting point because I was reading an article where they were saying, with this low-grade chronic inflammation, to consider other, what they call sickness behaviours like fatigue, altered sleep, as they can also be manifestations of inflammation. Excellent. Okay.

Tim: Absolutely. And you could add in there, are they physically inactive? Are they carry a lot of weight around the middle? We know that with adiposity, particularly central adiposity, those fat cells are not inactive. There's actually more macrophages in fat around our middle. And what do the macrophages do? I've already mentioned they're part of the inflammatory cascade.

So, metabolically, active fat around the middle is a risk factor for inflammation, as well as metabolic syndrome, CVD, type 2 diabetes. But having a poor diet, poor sleep, as you've mentioned, that's a big issue. Pollution, infection, if you smoke, all of those can worsen inflammation, which then can tip you over the edge for the clinical presentation that the person has today, be it, you mentioned Hashimoto's, rheumatoid arthritis, and so on.

Lisa: Okay. Really interesting because a lot of patients have multiples of those going on. They don't just have the chronic infection and the sedentary lifestyle, they've got issues with their diet, and dysbiosis, and so on.

Tim: Yes, all of those are related. And that's really just with clinical judgment. You don't just treat the condition, Hashimoto's or rheumatoid arthritis, you look at all these other factors, which will impact upon inflammation that's underpinning those conditions in the first place.

Lisa: I know within your latest edition of the textbook, there's a lot more focus on intestinal dysbiosis. So, I'd love to hear your thoughts on the microbiome and dysbiosis and how that impacts inflammation.

Tim: Yes. So, the gut microbiota is the hottest of hot topics, just for the amount of systems it impacts upon our body. And while there is unlikely to be one perfect healthy microbiome that is the same for everybody, it's highly individualised. We know that as you decrease diversity, that's the number of distinct species, that certainly is a big marker for dysbiosis. Now, the problem with when you change your gut microbiota is some of the metabolic products that they're involved in producing, one of them, of course, is going to be the short-chain fatty acids.

These are key mediators of reducing inflammation in our body. So, if you think about more of a positive diet that's full of minimally processed plant-based foods, has lots of probiotics in it, that is certainly linked with production of more of these short-chain fatty acids. And they're almost what I consider key signalling molecules in reducing inflammation. The opposite is true with poor diet and all the other lifestyle factors that go with it, then you see dysbiosis.

And by inference, then that means you get less of these metabolic products. And that will help promote or at least reduce the handbrake that's there that will control inflammation. So, that's probably one of the key mediators with our gut and inflammation. So, it's just the change in the metabolic byproducts, and it's probably the short-chain fatty acids, I think, are the key metabolites involved in this.

Lisa: So, when it comes to dysbiosis, I know stress can very much impact our microbiome. Can stress also impact inflammation?

Tim: Absolutely. If you talk about just life stress, and I'm not talking about just the small amounts of stress every now and then, constant stress, that will affect the HPA axis as well, cortisol responses, and so the cascade goes on. So, that's probably an alternative pathway feeding into inflammation or a different effector coming from just emotional stress.

But we know that our gut is not in isolation. There is a direct crosstalk between our gut and our brain, and that also controls our stress responses, certainly the vagus nerve is very important in that process.

So, even though stress can be external, it affects the brain. It can affect the HPA axis. Also, again, our gut microbiome will actually register that stress, and that can affect our gut microbiome. So, it's incredibly interrelated, but it's just giving a bit more detail to the molecular mechanisms that are occurring for all of these environmental lifestyle factors we know that affect our health.

Lisa: And I think I was reading some really interesting research on loneliness...

Tim: Oh, yes.

Lisa: ...yes, which is kind of a stressor in its own way. And I guess, for some time we've known that perceived loneliness is associated with poorer outcomes, increased risk of cardiovascular disease and so on. And there was a 2020 paper, actually, that examined the role of perceived loneliness and inflammation, and they found the individuals who perceived themselves to be lonelier actually had higher levels of the inflammatory cytokine IL-6.

And so I just find that really, really interesting because when we have patients in clinic, we're often very focused, I think, as practitioners on the diet, and I think we look less at trauma, and stress, and things like that. But it's such an important factor to consider when trying to reduce inflammation, too.

Tim: Yes. Loneliness is really considered to getting to an epidemic proportions in Western society. And the UK now has a Minister for Loneliness...

Lisa: Oh, wow.

Tim: ...but they're treating it so seriously because we have all of the health problems that go with it. Part of it can be related to stress, but also loneliness can mean your diet could be not as good because you are eating alone and you don't have as much motivation to make changes. Once depression kicks in, that will exacerbate a whole lot of problems. So, yes, that's a great example that loneliness will be related to all the other factors, but in the end, it still will affect inflammation and it's affecting inflammation. It's going to affect all of the diseases, of which there are way too many, that are linked to it.

Lisa: So, what about sleep? Because I know a lot of my clients really, really struggle with getting to sleep. They tend to stay up really, really late. Has that got any impact with inflammation?

Tim: Absolutely. So, if you look at a lot of research done now in sleep, particularly in shift workers, so that's a great model to understand, they have much high risk of obesity and metabolic disease, insulin resistance, and all of that is underpinned by inflammation as well. Shift work and poor sleep habits could also be a marker for poor diet, which, of course, will affect your gut microbiome and inflammation. All of it's related.

So, in that case, poor sleep habits that go on affect all of our systems. It can affect your mental health and depression as well, all related. So, yes, getting good sleep habits is really a cornerstone. Diet, sleep, exercise, probably the Holy Trinity of good health. Get that right. Plus, of course, social connection, all the other things, but all that is really important.

Lisa: Yes, definitely. So, we've talked about some of the things that cause inflammation. A lot of conditions have that unresolved chronic low-grade inflammation, right? So, do you want to chat us through some of those?

Tim: Okay. Let's go through a bit of a list and feel free to add in a bunch more, Lisa. So, cardiovascular disease, type 2 diabetes, metabolic syndrome. Autoimmune diseases, so rheumatoid arthritis, Hashimoto's. Inflammatory bowel disease, that's going to be Crohn's and ulcerative colitis. And then you're getting into more the neuro ones, so potentially Alzheimer's disease, multiple sclerosis. Have I missed any out? There's a bunch more you can throw in there.

Lisa: Pretty much all of them, right? So...

Tim: Oh, cancer. There are many forms of cancer, particularly colorectal and breast have some inflammation as part of that as well. So, there we go. All the big ones.

Lisa: Yes. So, we've really go to be considering, I guess, unresolving chronic inflammation in pretty much every client that comes in, don't we?

Tim: Yes, correct.

Lisa: Yes. So, I think a lot of practitioners really focus on trying to reduce inflammation when a client comes in, and there's obvious chronic inflammation. But is there a difference between just reducing inflammation and resolving inflammation?

Tim: There certainly is. So, maybe a good analogy would be if you've got a raging fire burning. And if it's in a closed space, if you reduce the oxygen to it, the fire will dampen down, but it will likely still be there. So, that's helping reducing it. But if you want to resolve it, you throw a bucket of water on there and you get rid of the inflammation that's there. My own research program has been a lot of work in pressure ulcers.
So, pressure ulcers are a chronic inflammatory condition, just that constant blocking of the blood supply, say, to the hip, or to the leg, or to the heel results in a wound. But that wound doesn't heal because the inflammation just stays there, and it stays there, and it stays there. Once you can help resolve the inflammation, then that allows the body to heal itself and to heal the wound.

So, there's one thing to help reduce inflammation, and there's lots of lifestyle things to do that, but it's another thing to resolve it completely. And that's sort of getting into, I guess, a lot of the chronic diseases can resolve the inflammation. That will certainly help with the condition that's being treated. So, yes, there's a subtle difference between them. Reducing is good, but resolving is just as important.

Lisa: Yes, because I've read in some papers, there are broken pathways, so the pathways that help to reduce our inflammation aren't actually doing that properly.

Tim: Yes.

Lisa: And it's typically in a lot of those clients that you mentioned, the ones that are obese or have that chronic inflammation, metabolic syndrome, and so on.

Tim: Exactly. And so there's a lot of... This is very much emerging research, but looking at those metabolic pathways, and here we're talking about our essential fatty acids of the omega-3s and omega-6s. So, they are metabolised in the longer chain forms. For the omega-3s, it's going to be EPA and DHA. For the omega-6s, it's arachidonic acid. But it doesn't end there. There's a whole cascade of further metabolites of those fatty acids, which are involved in helping to resolve inflammation. And it's pretty complex stuff. It's emerging research, but there's interest in these metabolites to help really nip the inflammation in the bud.

Lisa: Okay.

Tim: So, these are called specialised pro-resolving mediators, and it's something you'll be hearing more about in the future. So, it's really the next step from our fish oil and arachidonic acid. It's really what they're metabolised into. And there's a whole very complex pathway that I still struggle to understand. It's fascinating stuff.

Lisa: Totally. Yes, I have been doing some reading about the specialised pro-resolving mediators as well, and my understanding is that we all produce them naturally in that acute inflammation.

Tim: Yes, correct.

Lisa: But where there is obesity, where there is autoimmune conditions, for example, sometimes we don't actually convert the omega-3s to the SPMs.

Tim: That's right.

Lisa: Yes. So, I'm really interested in Hashimoto's, and I found this study, which kind of blew my mind, that there were lower levels of these specialised pro-resolving mediators in individuals with hashi’s, and their antibodies went up as the SPMs went down, which I thought was really, really interesting.

Tim: Fascinating.

Lisa: Yes. So, they haven't done any study, actual studies giving the SPMs yet, but they were saying that that chronic unresolved inflammation is probably a driver for those autoantibodies going up, which I just think is super interesting.

Tim: It's a perfect way of explaining it, that that fish oil may help reduce inflammation, but to really resolve it, you need the further metabolism of, the EPA, DHA, and so on. And if there's blocks, these things happening internally that are affecting that, that could be an issue. Hence, the idea in the future of taking the actual SPMs, which are the downstream metabolites of EPA, DHA, and arachidonic acid to help resolve the inflammation rather than just damping it down.

Lisa: Absolutely. Okay. So, we've talked about the underlying drivers and some of the conditions associated with inflammation. I'd love to talk to you about lifestyle. What are your favourite lifestyle strategies to utilise with clients that have this chronic unresolving inflammation?

Tim: Okay. We could talk about a whole bunch of them, but I'll talk about two that are really important.

First of all, it's going to be diet, and it's going to be about focusing on prebiotic fibre. I mean, there's so many different types of prebiotic fibre we're actually learning more and more about there's a whole bunch of different chemicals and plants that can have that gut microbiome. Even polyphenols, for example, now can be metabolised by the gut microbiome. In fact, they're important in actually the metabolism of them.

So, a simple thing I'd say to so many people is that when it comes to diet, don't try and hero one particular food as being the anti-inflammatory food. It's a diversity of foods, and colour is just a fantastic guide to a diversity of prebiotic fibre in all plant foods. So, colour is a simple guide rather than just, it has to be some turmeric, or it has to be fish oil, or it has to be this, but they're all important. But colour is the best guide.
And actually, physical activity. Physical activity is a really potent anti-inflammatory activity. When you're doing it, it's inflammatory because we know that it's painful, it hurts, and it's good, but that metabolic stress is good for us long-term. So, physical activity is strongly linked with reducing inflammation. Combine that with diet, and guess what? Physical activity, independent of diet, changes your gut microbiome as well. So, everything comes back to the gut.

Lisa: Wow. Okay. That's really, really interesting because, oh, my gosh, I think a lot of us are really sedentary nowadays with modern lifestyle. Is there any sort of particular physical activity, or it doesn't matter? Anything?

Tim: I'm asked this so many times. It's whatever you like doing when you can do it, yes. Maybe there's an argument for more high-intensity short bursts of activity. But considering the average Australian, the low base, being as active as you can whenever you can. And if you like swimming, swim, if you like walking, walk, if you want to run, run, whatever.

Lisa: Yes, dancing. Yes.

Tim: It's all pretty good. Let the scientists debate and argue about it. It's small percentage differences in this sport versus that one. Get moving and then worry about if you want more weight-bearing exercise, hence running versus cycling. They’re both good exercise, but good for your bones, impact sport will be better than low-impact sport, but that's academic discussions. But get active, it's good for you.

Lisa: Yes. Okay. Excellent. And is there a duration, how sometimes we're told, "Okay, you've to go to do 10,000 steps," and that sort of stuff? Is there a specific duration that we should be recommending for clients?

Tim: No, because every bit throughout the day is additive. So, it doesn't have to be in this magical box of 30 minutes or 60 minutes. It all adds up throughout the day. In fact, only yesterday I saw a news story about this, that just a small little burst of 10, 20 seconds of high-intensity activity throughout your day, like really powering up a couple of flights of stairs, that has huge benefits.

So, you could combine a whole bunch of those little things throughout the day that are incidental that you wouldn't call going to the gym or going for a run. So, it's really whatever suits you, but it has to be active. And it has to put some mild stress on your body, and it has to be a constant part of what you do throughout the day, not just at one particular time.

Lisa: Yes. Okay. I'm just getting this vision of you running up and down stairs. Oh, okay. So, I like the way that you said that it has to be something mildly stressful…

Tim: Stressful, yes.

Lisa: ...but it has that opposite kind of effect. It's stressful, but it's not hugely stressful.

Tim: It's the good sort of stress. So, this is where, you know, exercise itself is stressful to the body, but then our body adapts to that. In fact, we only get stronger from it. It's some interesting stuff. So, taking part as antioxidants with exercise, with recovery, likely blunts the adaptation you get from exercise, but you don't get that from diet. So, you actually want these cascades, these metabolic systems happening from this mild stress, be it exercise, good stress, or it could be something stressful like sauna, for example, the good stress.

Lisa: My favourite.

Tim: I know it's a favourite topic of you. You've been looking into the effect of saunas on health.

Lisa: I have. I love a sauna, and I recommend them a lot for my clients because they're super relaxing. And then I had one a couple of weeks ago, and I thought, "Oh, I'm going to look up the benefits of sauna for reducing inflammation." And they're actually really, really good for reducing inflammation. And they found that the more times you do it during the week, the more it lowers your C-reactive protein, which I think is fantastic, another kind of intervention for patients to implement into their anti-inflammatory kind of strategy. And again, it comes down to what you were talking about, that exposure to heat is actually a mild stressor.

Tim: Correct, yes.

Lisa: It leads to that acute release of interleukin 6, which is inflammatory, but then subsequently leads to release of anti-inflammatory cytokines.

Tim: That's right.

Lisa: Yes. So, it's really interesting, I think, the way that the body works like that. And I think probably the cold water, the ice bath is probably a similar sort of situation.

Tim: Yes, that's exactly right. So, when you are controlling it, when you are signing up for this form of stress, it's actually quite a good thing. And one of the benefits of sauna is thought that it may mimic exercise in some ways. Because if you are very active, that is putting heat stress on your body. And we have these special proteins called heat shock proteins that are there to help protect our proteins, so body proteins, from things like heat and temperature, low oxygen levels, and changes in pH level. And those heat shock proteins can be anti-inflammatory.

So, exercise activates the heat shock proteins, so does a hot sauna as well. And a really fascinating research coming out of the effects of saunas on health. A lot of it’s observational though. So, obviously, the preferred population is going to be your Scandies because that's all part, everyone's got a sauna. Not so much here in Australia where we don't have access to them. But you can go to a local health club, a pool or so on, a lot of them have them. And if you enjoy it, even though it can be stressful once you get past that 10 or 15-minute mark because it gets hot, it's actually doing your body good.

Lisa: Yes, I was reading that, yes, typically you start just 5 minutes and then you build up to 10 minutes.

Tim: You build it up, yes.

Lisa: Yes. And then they say 45 minutes is the optimal, but not to go...

Tim: What?

Lisa: Yes, I know.

Tim: Oh, God. I'm yet to make it ever past 20 minutes. That's it. That's where the fun ends. That's way too much stress.

Lisa: Yes, definitely. Me too. All right. So, I know that you are a bit of a nature lover, I think, like me, so I was really, really interested to see that there's some good research coming out with green space reducing inflammation, too, which, again, I think is just another great intervention. So, can you explain a little bit about the concept of green space and how it reduces inflammation?

Tim: Okay. So, we don't need any research to tell us what we all know, that being in nature is good. We generally have lower stress levels, we find it enjoyable. We don't know why it feels good, but it's just a good thing to have. So, nature can be going out and leaving the city into the bush, but it also can be going into your garden or into a local park. So, just get the idea, it has to be in the forest.
But where nature can be of benefit for us, first of all, is reduce stress. So, the average person, if you are in nature, it's likely you are not being beeped out on the road by other cars, you're not having as many humans around you, hopefully not on your phone as much, you're not getting as much disruptions, that will lower your stress. And we’ve as already spoken, reducing stress will then affect your inflammation and your health. So, that's the first one.

Another one is that — this is observational research — but there is some research to show that people that spend a lot more time in nature have a different gut microbiota, because of, you're exposed to nature, all the bugs and things that are naturally there that may have an effect on your gut microbiota.

And the other thing is the things that you are breathing in from the plants, a lot of the volatile chemicals can actually have an effect, which is why, potentially, conifer forest maybe even better because there's a lot of terpenes, a lot of very...

You know, that’s that pine smell, you are breathing... I mean, that can affect your body. It's whole lot of plausible mechanisms. Or, you could say, "Forget the science, I just know that going for a walk in nature is good for me," and it is good for you.

Lisa: Definitely. I can definitely attest to those benefits. I always feel really, really relaxed, and, yes, just really good after some nature time. You can't help but be mindful, right, when you're outside in nature.

Tim: Correct.

Lisa: You're hearing all the bees, and the butterflies, and the leaves blowing. And I was reading a study where individuals were taken to a forest versus another group who actually had to go visit the urban centre or maybe Westfield or somewhere like that.

Tim: The opposite of nature. Okay, yes.

Lisa: Total, total opposite. And the individuals that were taken to the green space to the forest actually had much lower levels of those inflammatory cytokines, like tumour necrosis factor-alpha compared to the ones who'd been to the urban centre where nothing really happened to their inflammatory markers. So, it is a thing. I think it's really, really interesting.

Okay. So, let's go back to food because you were mentioning those polyphenols and those fibres.

I'd love to know a little bit more because I think individuals are completely bombarded with information on anti-inflammatory foods and anti-inflammatory diets. I was literally just listening to something, I think at the weekend, where they were talking about the anti-inflammatory diet, but there are so many variations and they were talking about how you shouldn't be eating capsicums because they're from the Solanaceae family and so on. And so I'd love to know your thoughts because it can be quite confusing.

Tim: You are completely right. So, there is no one perfect anti-inflammatory diet, but there are themes that come up. Now, first of all, there's lots of foods promoted as being inflammatory or anti-inflammatory. The evidence for most of that is quite minimal, so we don't have a lot of good human clinical trials to show that, yes, this food is inflammatory or this food is anti-inflammatory. Probably the few exceptions will be fish oil. Really clear. Take high-dose fish oil, certainly beneficial for rheumatoid arthritis, potentially lowering triglycerides and so on.

Curcumin coming from turmeric, certainly there's some pretty good evidence, the levels of meta-analysis showing its benefit in various forms of arthritis, potentially depression, PCOS, and so on. But after that, it's hard to pick at individual foods that can be good or bad, where the research is most, and what I prefer to focus on the message is dietary patterns. This is just a theme. The best-known dietary pattern is a Mediterranean-style diet. So, eating that sort of way is linked with lower inflammation.

So, it's not any one particular food, it's a combination of them. So, it's going to be lots of fibre from plant foods, there's green leafy vegetables, there's fish, plus, obviously, the olive oil, which is anti-inflammatory, all of that together is linked with lower inflammation. But you can't pick out what particular component of it. It's important.

So, I focus more on the dietary patterns. If you get the foods right, then the nutrients take care of themselves. And if you're eating more of the positive foods, it means you're eating less of the foods that are linked with inflammation, and that will help improve your health. So, generally, my theme is that plant foods, lots of plants, minimally processed. If you want to just be a vegetarian, that's fine. But having some animal foods, if you choose to, is generally not an issue.

A lot of the dietary patterns that are linked with low inflammation are fairly broad diets that align with the Mediterranean diet or dietary guidelines and so on. So, your version of an anti-inflammatory diet may be different from what mine is, but really think more guidelines of the good foods to include to allow your client to pick and choose what suits them rather than just the rigid list of eat these, don't eat those. We need to have a little bit of balance in all of that.

Lisa: Yes, I completely agree. And I think when we go back to the research on stress and HPA axis being a driver of inflammation, I think that we as practitioners have to be incredibly careful that we don't add to a patient's stress, and therefore, their inflammation with these overly rigid diets where they're then...

Tim: Perfect, yes.

Lisa: ...seeing food as a problem, and there's a lot of fear involved.

Tim: Yes.

Lisa: Yes. Okay. So, let's talk now about your favourite supplements for managing chronic inflammation. Let me know, what are they?

Tim: Okay. So, I'm an evidence nerd. I've been in research all my life. And when I look at... This is purely getting into the supplement area. When I started delving into all of the work with curcumin, generally it’s curcumin rather than in turmeric, I was quite surprised by what I saw, just the amount of positive research for a whole range of conditions. And I've touched upon some of them as well, so on exercise recovery, osteoarthritis, PCOS, potentially even depression as well.

There's a link with curcumin and depression, and it may not just be because of anti-inflammatory effects because curcumin can help upregulate a protein called BDNF, which is brain-derived neurotrophic factor, which is involved in plasticity and that actually may improve mental health. So, I think there's a good story about curcumin, but as you would know, there's no one single form of curcumin. It's quite a complex area to get into to know what supplement's going to be best. There's a whole range of different formulations on the market, proprietary ones. There's ones with piperine. You can take turmeric. So, what I say to people is, you can trial different sorts to see if you get a benefit from it. But I think there's a good case for the curcumin supplements.

And clearly, fish oil, definitely. The research about cardiovascular disease was excellent some years ago, now it's not as strong. So, maybe it's the fish more so than the fish oil.

Lisa: I have read papers on that, too, yes.

Tim: Yes, I've changed my view in the last 5 to 10 years, so it may not be as strong as what we thought. And this nutritional epidemiology is replete, but there's examples. You want to blame a nutrient as being the good or the bad thing to explain your health, but it's probably a more complex thing than that because food is more than one nutrient. It's a whole range of things in it.
But fish oil supplements certainly at high doses, we're talking 2.7 grams and above, can be effective in lowering triglycerides and rheumatoid arthritis. So, it's certainly a case for those. But I'm talking about EPA and DHA. So, to get 2 to 3 grams of EPA and DHA, you could be talking near to 10 grams of fish oil capsules, so it's higher dose.

Lisa: Yes. So, there's been a couple of studies on the SPMs for mild to moderate pain, and so that's what I'm using it for with exercise, with squats and things like that. I've noticed that, for about a couple of years, when I've been doing a squat and I get down in that squat position, there's always some kind of hip stiffness and impingement.

Tim: Okay.

Lisa: Yes, I've only been taking them for about a week, and already I've noticed, "Oh, I can get down a lot lower without feeling as stiff and..."

Tim: Fantastic.

Lisa: Yes. I think it's interesting. So, the research is emerging, but there was this recent pilot study published, and they combined the SPMs with the curcumin, which I thought was really interesting because you're getting...

Tim: God, you've hit the nail on the head for my two favourite supplements.

Lisa: Yes! So, you've got the curcumin, which is really good for reducing the inflammation, and then you've got the SPMs, which are great for resolving. And they actually found that, in adults with that mild to moderate pain, they were taking the SPMs and the curcumin combined for two months, and they experienced a significant reduction in that pain and an improvement in that physical functioning after 30 days, which I thought was really interesting because, definitely, when you have that loss of movement and you're in pain, it does impact on the mood so much. I feel like I've torn my calf, I broke my toe this year, and, yes, it really impacts your day-to-day life when you can't move and you're in pain.

Tim: Yes. Well, that's great that you're getting some benefit from these. So, it's great to hear some positive stories of taking these sort of supplements. And as we get older, particularly exercise, even though it's good for us, there can be a price to pay for it. So, anything that's going to alleviate some of that pain and stiffness from it is going to be a good thing.

Lisa: So, can you just go back to the polyphenols that you were talking about? What are your favourite polyphenol-containing foods?

Tim: Okay. So, there's about 8,000 different types of polyphenols. They're all throughout all the plant foods, you know, herbs and spices, coffee and tea have them. But when we look at the polyphenols that make it into our colon that can be fermented by the gut bacteria and have a benefit, typically, it's going to be the ones, the anthocyanins, and these put the blue in the blueberries. That's what anthocyanins do. As the pH changes, they can go red and their colour changes.

But I think these are probably the ones to focus on, which I'm a big fan of promoting berries, particularly blueberries for the polyphenols because we know that they can be metabolised by the gut microbiota. But once they're metabolised, they then impact upon the gut microbiota itself. So, a lot of the benefits we know from eating polyphenols and plants could be related to these particular ones. So, generally, I'm focused on those ones as good ones to consider.

Lisa: Okay. Very interesting. So, get into the blueberries.

Tim: Blueberries. Or it can be blackberries or strawberries because the colour is still the presence of anthocyanins. But as the pH changes, the colour changes, hence why colour is a great variety for health in food.

Lisa: Okay. Excellent. Anything else you think is relevant for us to add, Tim?

Tim: So, with today, inflammation, a lot of the advice for treating inflammation and resolving inflammation with lifestyle and diet are things you'd recommend to anybody as a matter of course, getting good sleep, getting stress under control, be it just changing some lifestyle changes, getting out in nature, eating better and just making small changes, eating more plant foods that have lots of colour, that have plenty of fibre in them, and being as active as you can.

Each one of those is additive for the benefits it'll have. It's not an all-or-nothing thing. Every extra serve of a colourful fruit or vegetable you have a day will be good. Every extra few minutes of activity you can do per today will be good for you. All of it is additive. Don't think that you need to have a perfect lifestyle. Just get it 80% right most of the time, and that will put you on the path to better health immediately.

Lisa: Completely agree. The key points I've taken from you today are, that as practitioners, we focus a lot on diet, but exercise is also incredibly anti-inflammatory. Getting on top of our stress is also really important to reduce inflammation. And lastly, the focus has been on reducing inflammation, however, re-examining chronic inflammatory diseases through the lens of failed or dysregulated resolution is also really important as reducing inflammation doesn't always resolve it.

Thank you so much for our chat today, Tim. It's been wonderful to speak to you.

Tim: It's been fantastic to chat with you and to share this really fascinating topic with your audience. And I hope for a lot of people, they've got some practical insights they can take away to help with their clients. So, thanks again for having me on.

Lisa: Thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Lisa Costa Bir, and thanks for joining us. We'll see you next time.

About Dr. Tim Crowe

Dr Tim Crowe is an Advanced Accredited Practising Dietitian who has spent most of his career in the world of university nutrition teaching and research covering diverse research areas of basic laboratory research, clinical nutrition intervention trials and public health nutrition, with over 40 peer-reviewed journal publications to his name. He now works chiefly as a freelance health and medical writer, scientific consultant and science communicator. He has an active media profile and a large social media following through his Thinking Nutrition blog and podcast

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