Dedication

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Text © Dr Rupy Aujla 2019

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The Doctor’s Kitchen Podcast

For more information, check out The Doctor’s Kitchen Podcast, where I speak to a range of experts about the topics covered in this book, drawing on the latest research. To listen to the relevant episode simply look out for Spotify links throughout the book.

Listen and subscribe to The Doctor’s Kitchen Podcast

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Contents

Cover

Title Page

Copyright

Dedication

The Doctor’s Kitchen Podcast

Introduction

Eat for your Brain

Eat for your Heart

Eat for Inflammation

Eat for Immunity

Eat to beat Cancer

Eat for your Mood

Eat for your Skin

Eat for your Eyes

Eating and living for Ultimate Health

1 Breakfast

2 Small plates

3 Rapid meals

4 Main meals

5 Desserts

6 Pastes, spices and teas

References

Index of Searchable Terms

Acknowledgements

About the Publisher

Introduction

I’m going to convince you that the opportunity of having the biggest impact on your health, is actually in your hands. In this book, you’ll begin to understand why, as a doctor, I’m so passionate about communicating that food and lifestyle is the best method of boosting health and reaffirming the concept of Plates over Pills. Quite simply, natural whole foods are the most advanced ‘drugs’ you could ever imagine and what we eat literally has an impact on every bodily system. I’m going to take you on a tour of why this is the case and how to take control and become the expert of your own health.

My name is Rupy. I’m an NHS medical doctor, founder of the non-profit Culinary Medicine UK, and I’m passionate about teaching everybody how to use food and lifestyle as medicine. I firmly believe the key to a happy, healthy life starts in our kitchen and this new book Eat to Beat Illness aims to continue and deepen the conversation we started in my first book. In my first book, I took you on a culinary journey through food in medicine, introducing you to the most fascinating and relevant concepts that prove why I believe that what you choose to put on your plate is one of the most important health interventions anyone can make. That book could be described as a manifesto, declaring why we need to take nutrition seriously. This, my second book, is a blueprint that demonstrates the intersection of diet and lifestyle factors across multiple medical specialities and how you can improve your ultimate level of wellbeing today.

As a doctor, it’s my responsibility to deliver credible, evidence-based information, which is why I’m very comfortable talking about the medicinal effects of eating well. Research is clearly demonstrating that improving our diet and lifestyle can enhance our health, and the traditional scepticism surrounding this topic is changing. More doctors are taking an active interest in this area either because of personal experience, anecdotes from their patients or simply because people are starting to demand more from their doctors than purely pharmaceutical fixes that are unsustainable.

The decision about which topics to discuss in this new cookbook has been heavily influenced by my experience as a doctor. Patients often tell me in clinic that they didn’t realise how food can impact a variety of conditions beyond heart disease and sugar control. Whether it’s their bones, arthritis, skin, or even sleep and mood, I always have a chat with my patients about food and discuss the relevance of nutrition and lifestyle to their overall health. There is an incredible amount of research looking at the impact of diet and it is the vital first step in the resolution of many problems. Every patient deserves this information and this new book will give you an insight into why I’m so vocal about the subject.

The principles of a healthy diet are simple: eat whole, colourful, mostly plant-based foods, including quality fats and plenty of fibre, and treat meat and fish as luxury items rather than staples. You’ll see this theme is woven throughout this book and I’ll also be dissecting exactly why these are so important by showing how this way of eating affects different conditions and parts of our body. Using the lens of science, the hundreds of research papers I’ve read and a good dose of common sense, I aim to demonstrate exactly why our food can be so impactful on healthcare today.

Although I touched on the clear link between food and overall health in the first book, here I examine in more depth how food affects our mental health, making us think more clearly as well as protecting us from disease. I discuss the impact of nutrition on skin quality and even how our eyes are affected by diet. It’s a fascinating and overwhelming field, but after reading these chapters you’re going to be even more motivated to eat well for life, and the simple recipes to complement the science will ease you into a deliciously healthy lifestyle.

On this journey we’re going to be talking about how simple changes to what you eat can protect and amplify your body’s own defences against ill health. Your immune system can be thought of as a complex network of specialised proteins, specific parts of the body and the population of microbes concentrated in your gut. I’ll walk you through how nourishing our bodies with incredible, accessible ingredients can ensure the correct functioning of our immune systems. What’s more exciting, however, is that the food choices I encourage you to make are culturally diverse and vibrant. The complex flavours found in widely available spices, for example, not only deliver exceptional taste, but have clear benefits to our health.

Most healthy-eating books concentrate on heart health and weight, but it’s not commonly recognised that lifestyle and nutrition can impact the most important organ in your body – the brain. I’ll be introducing you to a way of eating that embraces quality fats plus a variety of colourful and exciting ingredients that have scientifically recognised benefits for the brain. Eating a diet according to these principles helps protect you from one of the worst diagnoses we as doctors have to deliver – dementia – while helping you achieve a sharper, clearer mind.

I’ll also talk through the concepts of inflammation and oxidative stress, and tackle the uncomfortable subject of cancer. By covering all these topics, I hope to convince you that your diet is not simply something to manipulate to improve your aesthetic appearance or weight. We can certainly achieve those results with our lifestyle, but it is so much more important than just this. It is the very foundation for a happy life and for improving every aspect of your body’s function.

‘By approaching disease with a holistic perspective, of which food is a vital part, we can tackle the root causes of disease and help our patients truly live well.’

I have high aspirations to create a movement that considers food as medicine. I mean this in the most literal sense. I am not a naturopath nor an alternative care practitioner. I’m an NHS GP with an interest in emergency medicine. But I recognise that there is a lot we as conventional physicians can learn from the lifestyle principles of ancient medicine. By approaching disease with a holistic perspective, of which food is a vital part, we can tackle the root causes of disease and help our patients truly live well. Our plates are more powerful than pills and it is a key starting point for lifestyle changes that can protect against disease and boost our health.

Medicine is changing. Our global healthcare systems are struggling under the weight of treating lifestyle-related disease; without a lifestyle-related solution we must really address how we tackle this uncertain landscape. Now that we understand the molecular mechanisms by which dietary and lifestyle factors can affect chronic inflammation, mental health and the immune system we can confidently encourage nutrition as a health strategy. Judging from the medical conferences I attend globally, there has never been more interest in nutritional science and I’m hopeful that the future of modern healthcare has an immense focus on this subject.

Since writing my last book, Culinary Medicine UK has taken shape and a few medical schools are pioneering this method of teaching their students the foundations of clinical nutrition, as well as how to cook. Governments across the world are seriously considering nutrition training as part of public schooling, and cooking classes for patients could become part of treatment within the healthcare system. This is the future of medicine and I’m glad to see it unfold in small steps, but we need to accelerate its adoption. By purchasing this book, reading it and applying it to your own life you are now part of this conversation and contributing to the mission.

I believe my role as a health professional is to increase your awareness of the choices that will benefit your health. What you’ll find in this book is a diverse selection of recipes bursting with flavour, which will help empower you to make healthy meal choices that are easy to put into practice and infinitely beneficial to your wellbeing. They will focus on Speed, Simplicity of ingredients, incredible Flavour and high Nutritional value. This combination of information and recipes will keep you in flourishing health and I’m certain that you will find this way of life fulfilling and achievable.

As well as showing you the benefits of food, I’ve highlighted ‘Lifestyle 360’ changes that are relevant to each subject discussed in the chapters. I’ll be talking through the evidence behind deep breathing exercises, meditation practices and the importance of sleep and exercise through the lens of different conditions. It’s essential that everybody reading this understands the overall value of all these lifestyle factors and their impact on health. By utilising all these factors in unison, we can deliver a package that has great synergy and is, in essence, medicinal.

Although exercise and rest are critical to our health, eating is a particularly special feature of our lifestyle that naturally has greater importance to our wellbeing. Food is a universal language. Some of our strongest memories and emotions are linked to meals and, luckily for most of you reading this, it’s not purely to nourish. We celebrate with food, break barriers, solidify relationships over shared plates and communicate across cultures through the enjoyment of each other’s recipes. For this reason, although this is a ‘health’ book, my recipes will travel through different cuisines to reflect my belief that food the world over can be healthy and incredibly tasty.

Health starts on our plates. My promise to you is that although my recipes are influenced by the thousands of research studies I’ve read on nutrition and medicine, they are far from boring. My motto in the kitchen is Flavour as well as Function and you’ll learn how a delicious diet can create a more resilient body and mind. Step away from the scales and calorie counters and open yourself up to the wonderful world of eating to benefit your body and beat illness.

Eat for your

Brain

To kick off the ‘eating to beat illness’ discussion there is simply nowhere more fascinating to start than with the brain. Our most prized possession, it controls the centres for movement, thought, emotion and all the automatic processes such as breathing and heart rate that we do not have to consciously concern ourselves with. Quite literally, it is the most advanced machine ever known to us and, unlike the latest computer or most sought-after gadget, we all have one.

Our skull houses trillions of neural synapses (the junctions between nerve cells); these carry information across different brain centres that have specific functional roles for the body. The beautiful coordination of these electrical signals determines our actions and thoughts which are generated in these centres.

Of late, however, our brains are under fire. As a medical doctor, I witness the aftermath of conditions such as dementia and strokes all too often, and the prevalence of these is increasing.¹ These conditions reveal the vulnerability of the brain and body once these centres become affected and a culmination of insults have taken place.

Dementia is now the second leading cause of death in the UK and cases are rising.² Before you assume it is a natural part of ageing and a consequence of our population living for longer, there is clear evidence to suggest the contrary. Our lifestyles drastically impact the health of our brain and this chapter will help you understand why and how we can protect ourselves and optimise our brain power.³

Loss of emotional intelligence, inhibition of thoughts, motor-control deficits, memory impairment and many more signs illustrate exactly why diseases of the brain are so life-changing. It’s the experiences of these patients that push me to highlight the impact of diet and lifestyle and how we use the tools within our control. And it starts with our plates. I haven’t written these symptoms to scare you, but rather to highlight how beautifully coordinated our brains are and the consequences of poor lifestyle choices that are preventable.⁴ We tend only to value the importance of such organs when we have lost control of their precious functions and, while you may consider these conditions to only be relevant in later age, I’m here to inform you that looking after your brain is a lifelong process.⁵ The acceptance that you ‘naturally’ lose brain function as you age is a myth⁶ and I want to show you that looking after your brain can be enjoyable and delicious!

NEUROPLASTICITY

The ability of our brain to harness new neural connections, create new brain cells and positively adapt its function in response to stimuli from our environment is a concept known as ‘neuroplasticity’. It is one of the most fascinating and promising topics I have come across in recent years, and one where food and lifestyle play a pivotal role.⁷ Previously, it was not commonly believed that cells of the nervous system could regenerate or improve their function. It was conventional thinking that after childhood development, our brains were relatively ‘static’.⁸ However, research is demonstrating that not only can we change the synapses to improve our memory and the general functioning of our brain, but it could be a useful tool in the management of conditions such as neurodegenerative disease, like dementia.⁹ As you read, you will understand how diet and lifestyle are involved in this neuroplastic process in a way that can positively impact our brain health.

BRAIN INFLAMMATION

By changing the internal environment of the body, we can create the perfect setting for the cells of our nervous system to function optimally.⁷ Oxidative stress is a topic we will visit later on (here), but our brains are particularly susceptible to an imbalance in inflammatory proteins. It has been demonstrated in many studies that an ‘inflammatory western diet’ (high in sugar, refined carbohydrates, processed foods and salt) is disastrous for brain health.10, 11 In addition to putting people at risk of heart disease and stroke, which all raise the risk of neurological disorders, this western-style diet promotes inflammation that could disrupt the blood-brain barrier – a protective layer that surrounds the central nervous system and is integral to the health of your brain.¹⁰

In contrast, diets high in polyphenols (the types of plant chemicals that we find in colourful fruits and vegetables) are shown to reduce oxidative stress, which may explain their benefits to brain health.¹² The Mediterranean diet contains an abundance of different polyphenols and has long been recognised as one of the healthiest diets to follow for most people.¹³ In general, it consists predominantly of plant-based proteins, plenty of pulses, quality fats from nuts and seeds as well as colourful vegetables and oily fish. The diet has been shown to reduce the incidence of vascular disease that can contribute to poor brain health, and protects against diabetes, which we know is related to declining mental ability.¹⁴ Oxidative stress and inflammation are generally reduced in those adhering to a Mediterranean style of eating, which is in part explained by the sheer number of antioxidants found in the fruits and vegetables consumed.¹⁵

MIND DIETS

As well as the potential of diet and lifestyle to reduce the incidence of neurodegenerative conditions, I think it’s also important to bring attention to some of my patients’ anecdotes following improvements to their diet and lifestyle. I regularly hear comments such as, ‘I feel clearer in my head’, ‘my mood has improved’, or even, ‘I have so much more energy these days’. I recognise that these are soft and subjective statements but – despite no concrete, clinically validated method of measuring these outcomes – it gives me further hope that positive diet and lifestyle changes could improve the lives of everyone and not just those labelled with a condition. The improvements in mental clarity and mood could potentially be explained by reducing inflammation in the brain and oxidative stress, but there’s a lot more to learn in this field.¹⁶

A specific diet, appropriately called the MIND diet, was born out of some of the research looking at the correlation of high vegetable intakes and lower rates of dementia.¹⁷ This study, plus many others, have highlighted certain ingredients as beneficial to the resilience of our brains and I’d like to bring attention to them. It is by no means a definitive list of ingredients you ‘must have’ to protect your brain, nor is it a suggestion that we can radically renew our brain cells using these foods. However, it is an introduction into how incredible and impactful our diet can be to the function of our brain.³ Hopefully this will prompt you towards a healthier perspective that could potentially offer protection to this vital organ.

+ Greens These can impact multiple systems of the body including the brain, and are one of the most important parts of a healthy diet. Ingredients such as cavolo nero, spinach, rocket and sprouts contain high amounts of phytonutrients that drastically reduce inflammation in the body.¹⁸ Inflammation is a key component of why brain processes can become disrupted leading to symptoms of fatigue and sometimes low mood.¹⁹ Dark leafy greens are also a source of fibre that could benefit the gut bacterial population found in the digestive tract, which is also involved in the regulation of inflammation in the body.²⁰ Try the Harissa Beans and Greens (see here) for a spicy and delicious way of including more greens.

+ Omega-3-rich fats Found in oily fish, nuts and seeds, plus extra-virgin olive oil. The long-chain Omega-3 fatty acids are of particular interest, as they have been shown to promote the growth of brain cells which can help maintain the adaptability of the brain.²¹ These sorts of fats are potentially key components of the brain’s neuroplastic ability. Another benefit of nuts, seeds and oily fish in the diet is the quality protein they provide. These ingredients are broken down into amino acids (the building blocks of protein) which are used for the production of neurotransmitters, the chemical messengers of the brain that are created every time your brain centres need to send signals.²² Adequate stores of good-quality protein ensure the availability of these nutrients for the production of these essential chemicals. Try the Almond and Hazelnut Lentils with Capers (see here) to get nuts into recipes.

+ Berries These have received a lot of attention for being brain protective, with good reason. They are rich sources of polyphenols, including anti-inflammatory resveratrol and quercetin, but they may also be involved in the production of brain-derived neurotrophic factor (BDNF).²³ BDNF is involved in the maintenance and survival of nerve cells and could be a critical component of protecting the brain against disease but also enhancing cognitive ability. I always have a mixture of berries in my freezer at home for convenience because they are as nutrient-dense as fresh and much less expensive.

+ Whole grains Examples of these, including red rice, rolled oats and quinoa, are great sources of antioxidants, fibre and B vitamins, which are essential for brain health.³ The brain is a sugar-dependent organ but excessive sugar that disrupts the normal mechanisms governing the control of glucose in the bloodstream has been shown to negatively impact brain cells.11, 24, 25

This is why whole grains with the fibre attached are so important from the perspective of sugar control. Rather than blindly counting carbohydrates and removing anything labelled a ‘carb’ I urge patients to consider the quality of ingredients. Barley, corn and millet are nutritionally very different to breads, pasta and cakes, yet they are all lumped together under the same banner of ‘carbohydrate’. Whole grains are what we should be eating as they release sugar into the blood gradually and have not had the important nutrients stripped away from them. My Sri Lankan-style Oats (see here) are a great way of using whole grains in an unusual dish.

+ Water Perhaps the easiest to access and the most commonly forgotten ingredient of all is simply water. All too often I ask patients about their drinking habits only to discover a shockingly low amount of hydration! Discounting certain medical conditions that would contradict 2 litres of plain water a day, and excluding tea and coffee (which can actually dehydrate us), this is how much we should be aiming for. It is essential for nutrient transfer across brain cells, delivering oxygen as well as maintaining the integrity of cell structures. The simple act of hydration has been demonstrated in clinical studies to improve cognitive performance and there’s no reason why we shouldn’t all be drinking adequate amounts.²⁶ Drink for your mind.

+ Herbs and spices Most of these contain key antioxidants and phytochemicals (chemicals produced by plants) that can reduce oxidative stress.²⁷ As a general rule of thumb, using simple kitchen herbs like rosemary, basil, oregano and mint in your cooking is a great way to reduce inflammation and improve the enjoyment of food. Certain chemicals labelled ‘adaptogens’ or nutraceuticals, including ashwaganda, curcumin and gingko (to name just a few), have been given a lot of attention in the press over recent years, claiming to boost brain health with regular consumption. While I welcome greater research into compounds that are safe and well tolerated, the biggest impact on brain health is not going to come from a nutraceutical pill. I wouldn’t like anyone to believe that simply taking supplements in isolation is the best way to protect your brain. It’s going to be your plate and lifestyle that has the biggest impact.

LIFESTYLE 360

I could talk extensively about micronutrients, including vitamins E and D, or the power of individual phytochemicals, but this would neglect the importance of ‘food synergy’. We don’t eat nutrients in isolation and I’m a firm believer of an integrated dietary approach. By overanalysing single elements of our diet we miss the wider picture about the combinations of food we consume and how difficult it is to tease out what’s having an impact. We need to experiment with new and delicious ingredients but in addition, the synergistic effect of lifestyle alongside diet is a powerful combination to be reckoned with.

+ Mental training and stimulation These have been observed to increase a type of material in the brain called ‘grey’ matter that makes up parts of the brain involved in emotion, coordination and perception.²⁸ You don’t have to just do Sudoku or mathematical exercises – meditation and mindfulness regimens have also been shown to demonstrate increases in grey matter.²⁹ Playing a musical instrument, singing or any activity that focuses attention may lead to benefits and are worth the time investment to keep your brain healthy.

+ Chronic stress It has been shown that a high level of stress induces structural changes in the brain, which suggests our emotions are potent modulators of our brain’s anatomy.30, 31 In clinic, I emphasise the need for simple stress-relieving strategies, such as yoga, deep breathing and meditation, that heighten neural activity in the brain’s pleasure centres and improve our tolerance to stress.³² These powerful tools are accessible to everybody and, if taught appropriately, research shows can be very effective.

+ Exercise High intensity interval training (HIIT) and endurance exercises reduce the incidence of cardiovascular disease, which would ultimately reduce the likelihood of cognitive decline. But exercise itself also induces the production of ‘neurotrophic’ factors that enhance nerve cell generation and protect against shrinkage of the brain that occurs as we age.³³ Our bodies are designed to move constantly, but I find that many patients are confined to their desks in their working environments. Whether it’s a case of getting a standing desk or taking the stairs, I advise to try to move as much as possible throughout the day – exercise is not confined to the gym. Your brain will thank you for it.

+ Sleep Sleeping to both protect and greatly enhance brain function is the lowest hanging fruit, yet few of us practise good sleep hygiene. The constant stimulation from TV platforms and mobile electronic devices creates an environment associated with disrupted sleep. During sleep your brain’s lymphatic system (the system that removes toxins and waste products as a result of normal cellular processes) gets to work to clear debris that can impact the functioning of your nerve cells.³⁴ There is a clear link between poor sleep and a higher likelihood of cognitive decline, and on the other side of the spectrum, boosted cognitive performance when you are well rested. Getting a good quality 8–9 hours of rest per 24 hours is one of the simplest ways to boost brain health. Make yourself a promise: try it for 7 days and monitor how you feel. It will revolutionise what you prioritise.

By employing all these tactics we can positively impact our brain on multiple levels. We have the power with our diet to reduce inflammation, stimulate brain growth factors, promote neuronal cell production, reduce oxidative stress and improve many other processes that we have yet to discover. As well as all these dietary and lifestyle changes being protective, the aforementioned activities are also being considered in management to improve outcomes or prevent further decline in patients to good effect. This is where we need to invest more of our time and resources, but I’m making this vital information accessible to you right here. Don’t wait for the prescription pad. Take advantage of these points and start looking after your brain health right now. As you’ll discover in all the other chapters in this introduction, eating and living well doesn’t solely effect your brain health, but rather your entire ecosystem.

Eat for your

Heart

If you’re tempted to skip over this chapter because you’re in your mid-twenties or early thirties and you believe heart disease is only something of concern in later life, think carefully about flicking past these pages. Heart disease isn’t something that suddenly becomes relevant as soon as we reach a certain age threshold. We build the foundations for a healthy or unhealthy heart in our childhood and we are starting to see the early signs of atherosclerosis (narrowed, inflamed arteries) in those as young as teenagers.³⁵ But rather than scaring you into booking a CT angiogram to determine the state of your vital organ, I want to show you how much control you have using your fork.

Our heart is a complex machine that generates electrical energy to synchronously contract its muscles, pumping blood around our network of vessels. The blood contains vital oxygen molecules, as well as nutrients to feed every cell in our body, but the heart itself is desperately reliant on the same nutritional need. Micronutrients like potassium, magnesium and calcium are essential to ensure the contractility of this muscular organ that, hopefully, will never stop throughout our entire existence.

If you hit the gym harder than usual and you’re dehydrated, or perhaps you haven’t had adequate nutrition prior to your workout, your muscles will feel stiff and generally fatigued. Feed yourself the right fuel, however, and you’re less likely to feel the negative effects of training. Our heart muscles are categorically different from the skeletal muscles in our limbs, but the general principles of feeding our muscle tissue still apply. It’s vital to ensure your heart is adequately nourished to perform its function throughout its lifetime and make lifestyle choices that nurture this beautiful, industrious machine. Thankfully, this isn’t hard, and the food you can enjoy is still incredibly delicious and exciting.

It’s important to remember that the heart (like most organs) is incredibly resilient. As demonstrated by some impressive studies, reversal of atherosclerosis can be achieved with a lifestyle that encourages your body to look after itself.³⁶ A number of cardiologists have demonstrated, using both blood tests and imaging to look at the vasculature of the heart, that a healthy lifestyle can reduce blockages of the arteries.37, 38 This is absolutely groundbreaking and something not thought possible up until a few years ago. In fact, some lifestyle medicine programmes have become so effective at reversing cardiovascular disease that they’re now covered by American health insurers.39, 40

But rather than trying to just reverse heart disease, I want to focus on the habits that will prevent the life-changing event of a heart attack that happens to over 100,000 UK citizens each year. Yes, there is evidence to suggest that we can drastically improve post-heart attack symptoms with intense lifestyle changes, but the better and more effective aspiration is to prevent that stage in the first place.

THE MEDITERRANEAN WAY

The Mediterranean diet has been heralded as the most heart-healthy diet and evidence supports this. When we look at large population studies, it’s clear that a Mediterranean way of eating, that includes plenty of fruits, vegetables, good-quality oils and healthy fats, significantly reduces the likelihood of high blood pressure, strokes and heart disease.41, 42 A representative dish of how to eat with this focus in mind is my Roast Walnut and Squash Medley with Persillade (see here) or the Aubergine and Walnut Ragu (see here).

We can analyse why this may be the case by examining the components of a Mediterranean way of eating. The focus is on colourful vegetables such as tomatoes, squash, lentils and dark leafy greens, which are fantastic sources of the micronutrients necessary for optimum cardiac muscle function.43, 44 The most extensively studied of these micronutrients include potassium, calcium, magnesium and co-enzyme Q10,⁴⁵ but there are a huge number of other plant chemicals found in the same foods that we still haven’t fully investigated the effects of.⁴⁶

There are now over 30 years of data, including the results of the Lyon Heart Study, PREDIMED studies and other large research projects that all point towards Mediterranean-style diets and lifestyle modifications as being significantly more effective at prevention of cardiovascular disease than drugs combined.⁴¹ To put this another way, if you change your lifestyle and eating habits, it has a more powerful effect on your health than any number of medication combinations I can prescribe. This is simply not common knowledge among our population, nor medical professionals and, quite frankly, it should be printed on the front door of every cardiac unit and general practice surgery in the country. Considering the exorbitant cost of medications and interventions directed at preventing cardiovascular events that our healthcare system invests in,⁴⁷ there is simply no excuse for why diet education should not play a central role in healthcare. We do ourselves a disservice by not engaging in this conversation and it is where we need to direct our resources.

NUTRIGENETICS

If you happen to have a family history of heart disease, you may be thinking to yourself that your genes are your destiny and there isn’t much you can do about your ‘dirty DNA’. On the contrary: studies have shown that we are more in control of our heart disease risk than previously thought. Our genetic blueprint is inherited from our parents; this information is stored in every cell of your body and it is unchangeable. However, we can change the OUPUT of our genes by changing what we put IN to our system.⁴⁸ The ability to change the expression of our genes is a concept I introduced in my first book. Nutrigenetics, nutrigenomics and epigenetics are among a few novel science disciplines that focus their attention on the role of nutrients and bioactive food compounds in gene expression.⁴⁹ When I personally learnt more about this field, it revolutionised my perspective on just how important food and our lifestyle is.

Once we begin to understand and believe in the power of environmental influences on the very foundations of our existence, it becomes clear why diet is one of the most technologically advanced treatments we have in our armoury against disease. When you consume food it ‘speaks’ to your DNA and this communication can either lead to an overall positive or negative outcome. By introducing colourful foods, nutrient-dense ingredients and good-quality fats (which all the recipes in this book contain) we not only provide micronutrients and proteins for heart function, but we are also changing the messages transmitted via our DNA.⁵⁰ Cardiologists are now warming to the idea that nutrigenomics has a role in their speciality and I see more specialists attending lectures in nutrition, engaging with me on social media and at talks, wanting to learn more. This area of research gives us further mechanistic information about why particular diets like the Mediterranean diet are so cardio protective⁵⁰ and I’m sure biomedical informatics will help tackle the complexity of this field.

What we can be certain of is that the root cause of – and solution to – the clear majority of cardiovascular diseases that I see in the emergency department and primary care is manageable with lifestyle. This fact alone should give us a clue as to where we should be concentrating our attention and resources.

STOP THE STRESS

Beyond the nutrients necessary for contracting the muscular walls of our heart, this organ is vulnerable to ‘oxidative stress’, a topic we discuss in the chapter exploring inflammation (here). High levels of inflammation have been shown in many animal and human models to be detrimental to the walls of arteries.⁵¹ Oxidative stress can be created by high blood pressure, smoking, as well as high-sugar diets that can lead to the creation of ‘advanced glycaemic end products’ (AGEs). These products concentrate in parts of the heart vessels creating inflammation that can lead to plaque formation.⁵² By ensuring your lifestyle reduces inflammation, limits foods high in sugar and refined carbohydrates (like white rice, bread, pasta, cookies and cakes) you can prevent unnecessary oxidative stress and fuel your body’s natural inflammation-balancing mechanisms.

A Mediterranean-style diet has been shown to reduce oxidative stress, lower blood pressure and improve the health of blood vessels.⁴¹ In addition, a diet high in green vegetables such as broccoli, parsley and sprouts not only contains oxidant scavengers like vitamin C and heart-stabilising minerals like magnesium,⁵³ but phytochemicals including sulfurophane, indole-3-carbinol and quercetin that are known to be potent anti-inflammatory ingredients.⁵⁴

‘Whole sources of fat such as pecans, walnuts, sunflower seeds and minimally-processed extra-virgin olive oil are fantastic additions to your diet from a heart-health perspective.’

BALANCED FATS

Despite years of being told fat should be stripped out of our diets, sources of good-quality fat such as nuts, seeds and extra-virgin olive oil feature heavily in Mediterranean diets which are heart healthy. The detrimental low-fat message needs to be addressed. It’s been heavily over-simplified and it’s a confusing topic for many patients who still believe all sources of fat are harmful. To put it simply, whole sources of fat such as pecans, walnuts, sunflower seeds and minimally-processed extra-virgin olive oil are fantastic additions to your diet from a heart-health perspective. Not only do they contain key minerals like selenium and magnesium but they provide antioxidants such as vitamin E, which can protect the heart from oxidative stress.⁵⁵ Algae oil and wild oily fish also contain long-chain Omega-3 fatty acids that have been shown to be anti-inflammatory⁵⁶ and vital additions to a heart-healthy diet.

Two types of fatty acids, Omega-3 and Omega-6, have been given a lot more attention in studies trying to explain the rise of heart disease in western countries. Omega-6 is found in cereals, wheat and animal products but also within vegetable oils, nuts and seeds. Omega-6 is generally thought to be pro-inflammatory but, as we will learn in the inflammation chapter (here), the process of inflammation is essential for our body and this is why we need some sources of Omega-6 in our diet. The issue appears to arise where the ratio of Omega-6 to Omega-3 in our body falls out of balance. Throughout our evolution we would have had equal amounts of 3 and 6 or a ratio between 1:1 to 1:4.⁵⁷ However, western diets high in poor-quality industrial corn and soy oils, refined cereals, wheat and animal products tip the balance to one that has a much higher ratio of Omega-6 than is sensible for human health.

The mechanism by which different fats impact our health is more complicated than simply turning inflammation on and off. Fatty acids modify the blood’s ability to clot and even influence gene expression of cells in our vessels.⁵⁸ To put it simply, it’s all about ratio, but rather than suggesting we all diligently calculate our Omega-3 to Omega-6 percentages, my advice would be to concentrate your fat sources on whole foods such as nuts and seeds. Use minimally processed oils like extra-virgin olive oil and limit your intake of biscuits, fried foods and refined snacks like crisps. Follow these principles and your ratios are likely to be optimal for general as well as heart health without having to obsess about the numbers.

Our plates are a gateway to using the thousands of compounds that assist our body’s inherent ability to look after itself. Recipes such as my Aubergine and Walnut Ragu (see here) or the Jambalaya (see here) are great examples of the types of food we need to concentrate our diet around. These include vegetables, fruits, spices and specific fats that help reduce our risk of heart disease through a multitude of cellular processes. Here are some of the foods I regularly recommend in clinic to patients interested in heart-healthy meals:

+ A rainbow of colours There is a significant body of clinical data and large studies to demonstrate that antioxidant-rich diets reduce blood pressure and cardiovascular risk⁵⁹ and, as a general rule of thumb, colours mean antioxidants. Look for a rainbow of colours in your diet and you’re likely to be including a plethora of micronutrients that will positively impact your heart. Of particular note, I like to include red and purple foods such as berries, beetroot, red cabbage and grapes. These contain phytochemicals such as the betalains and anthocyanins that have been shown to relax blood vessels and lower high blood pressure.60, 61, 62

+ Calcium and potassium These minerals are essential for vascular health. You’ll find calcium in ingredients such as chickpeas, puy lentils and sesame seeds, and both potassium and magnesium are abundant in dark greens such as cavolo nero, spring greens and Swiss chard. The heart is an energy-generating organ that relies on these minerals to appropriately conduct electricity through its tissue fibres. By eating these types of foods, you ensure the availability of these essential nutrients to safeguard optimal heart function.

+ Fibre As well as the minerals contained within beans, legumes and pulses, these foods offer a variety of fibre sources. As with most aspects of health, your gut microbes have a significant role in cardiovascular disease and there is a clear ‘gut-heart’ connection.⁶³ Inflammation is an important contributor to the mechanism of cardiovascular disease and nurturing a robust gut population with plenty of fibre sources reduces inflammation and can prevent damage to arteries that can cause heart attacks and strokes. In addition to pulses and legumes, chicory, garlic, onion and leeks are fantastic fibre sources that will encourage a healthy microbiota.

+ Good-quality fats These have been shown to have positive effects on the expression of your genes, which create a more favourable cholesterol profile and improve fat distribution around your body.⁴⁹ The fats to focus on are those from whole plant sources: concentrate on the least refined types. These include walnuts, pistachios, almonds, oily fish, cold-pressed virgin oils (like avocado, rapeseed and olive) and seeds. These tend to have higher amounts of unsaturated versus saturated fats, but I’d rather you pay attention to foods rather than the biochemical profiles of ingredients. I’ve found in clinical practice that it’s a waste of mental energy to try and entertain the different arguments for and against certain fats. The reality is, all fats contain both unsaturated and saturated categories in varying proportions and subtypes. It doesn’t make any sense to suggest we should remove all saturated fats from your diet when every fat you can think of will contain some amount of saturated fat. Trust me on this one: your heart will thank you for focusing on plentiful whole, largely plant-based fats and enjoying fats from animal products like meat and dairy on occasion.

LIFESTYLE 360

Diet is just one of the many strategies to positively impact metabolism, genetic expression, body-fat distribution and many more processes that benefit your heart.⁶⁴ Now consider the extra medicinal benefit of complementing delicious food with lifestyle modifications. As a starting point, the recommendations of smoking cessation, alcohol moderation and exercise are essential, but this is not where lifestyle advice stops. Over and above these well-known factors are other extensively studied recommendations that I’ve outlined below.

+ Sleep If there was one thing I could change about my patients’ habits, from the perspective of improving heart function, it would be to get more sleep. Sleep deprivation is correlated with higher blood pressure, higher measures of inflammation and worsening cholesterol profiles, all of which contribute to heart disease.⁶⁵ Findings from multiple studies demonstrate that a lack of sleep causes raised stress hormone levels and activation of your ‘fight or flight’ system which leads to changes in your mental ability as well as causing strain on your heart. In addition to the direct impact, after a poor night’s kip your brain sends signals to make you hungrier, making you more likely to crave that sugary croissant or salty fried snack, which will compound the detrimental impact.⁶⁶ As with most things in medicine it’s not about quantity but quality. Seven to nine hours a night is a general rule of thumb, but try measuring how long you sleep at the weekend without an alarm waking you the next day and being aware of how refreshed you feel. This will give you a personal indication of generally how much sleep you should be aiming for during the working week, too.

+ Stress-relieving techniques As an adjunct to improving stress hormone levels and reducing inflammation, stress-relieving techniques and mind–body interventions including deep breathing exercises, meditation and yoga can have positive effects on heart health. It may seem slightly leftfield for a conventionally trained doctor to be recommending this, but actually mental stress has been shown in many studies to be a significant contributing factor to heart disease.67, 68 Stress activates the immune system to create an inflammatory environment as it perceives the body is ‘under attack’ and this can lead to oxidative stress that damages and weakens blood vessels. These same stress hormones can increase sugars in your bloodstream, which can impact fat production by the liver as well as cholesterol ratios. There are robust clinical reasons behind why one of the most effective lifestyle programmes for heart disease, the Dr. Ornish Program for Reversing Heart Disease, has an intense focus on stress-relieving techniques. We would all benefit from one of these in our daily routine and you can check the website www.thedoctorskitchen.com.

+ When we eat The timing of when we eat has been shown to have a significant impact on our blood sugar, cholesterol ratios and the overall impact on our heart health.⁶⁹ It is an unfortunate and well-recognised fact that shift workers who experience regular disruption to their circadian rhythm (the rough 24-hour cycle that all our cells are aligned to) have a greater risk of heart disease, obesity, dementia and generally live shorter lives.⁷⁰ However, there are certain practices that even shift workers can employ to mitigate the effect of cycle interference. Studying this population of workers has led to some interesting recommendations that even those who are lucky enough not to have to do odd working patterns can employ. As a guide, it has been suggested that night-shift workers should eat at the start of their shift (dinner) and at the end (breakfast) to minimise the negative impact of eating when their bodies should be asleep. This practice of ‘defining periods of eating’ to a rough 10–12-hour window (during hours that you are awake) has also been shown to have favourable effects on markers of disease risk.71–73 As a general rule of thumb, this practice allows cells of your liver, pancreas and gut to better tolerate the food you ingest so that it is less likely to cause blood sugar spikes and cholesterol imbalances which can affect your heart. It’s a simple guide that not only gives your gut a rest (allowing it to perform the numerous other functions it needs to do) and minimises disturbance to your important rhythms, but also it also discourages mindless snacking in the late evenings that most of us do out of boredom.

These simple diet and lifestyle practices are incredibly powerful and accessible to the entire population. Combining these with the other chapters that demonstrate how to improve your immune system, balance inflammation and relieve stress produces a collective medicinal package that is so powerful in the fight against the biggest killer in the UK today. Our food and lifestyle are powerful tools that I encourage you to use, whatever your age for the optimal functioning of this principal organ.

Eat for

Inflammation

It’s amazing how many times I see ‘inflammation’ as a concept coming up in different medical specialities as one of the potential causes of disease. It has almost become a unifying theory that links conditions of the modern world to our lifestyles. You might think I’m just talking just about the swollen ankle that happens after an injury, or the redness that surrounds a cut on the skin, but high blood pressure, heart disease, dementia, diabetes and mental health problems all have links to an imbalance of inflammation in the body at a cellular level.⁷⁵

WHAT IS IT?

I see many products being labelled as ‘anti-inflammatory’ and I think there is a lot of misunderstanding about what inflammation really is. This chapter will give you more of a tangible idea about the role of inflammation in our health as well as how to tackle the problems related to an imbalance of this essential system.

Inflammation is your body’s normal response to events that cause damage to cells, like an injury or infection. The process involves proteins being released in response to the damage and these proteins send signals to the cells of the immune system to come and help. This is usually a short-lived, adaptive response that involves coordination of many complex signals and organs.⁷⁴

The inflammation process is very important: without it our cells would not be aware of bacteria causing something like a simple skin infection, and leaving the bacteria undetected in our body could lead to an uncontrolled severe infection with significant consequences. Inflammation is critical for infection prevention and to keep the body alert. We have, in essence, evolved to be able to fight infections, and a host of other stressors to the human body, effectively and swiftly using inflammation as an important tool.⁷⁶

However, inflammation is meant to be a temporary, protective response. Whether that’s a reaction to a knee injury or an infection in your digestive tract, inflammation is essentially a big nudge to your body, letting it know something is not quite right and needs to be addressed swiftly. Inflammation is meant to be a short-lived process that resolves over hours, days or, at worst, weeks. However, what we are witnessing in modern society is persistent, low-grade inflammation over longer periods of time, also referred to as ‘meta-inflammation’.⁷⁷ Today we have a number of seemingly small and insignificant stressors that create subtle inflammation over long periods of time and can manifest in a multitude of symptoms. These range from the subtle and vague, such as fatigue, lack of mental clarity and skin irritation, to the more pronounced, including pain, mood disorders and heart disease.78, 79 These symptoms will obviously overlap with other causes, but we are becoming more aware of the damaging effects of inflammation imbalance that is at least in part to be related to these and many other conditions.

Examples of stressors potentially causing low-grade inflammation include excess sugar consumption, psychological stress, sedentary behaviour, accumulation of fat tissue and nutrient deficiencies (including vitamin D, Omega-3 and different micronutrients). Depending on our ability to tolerate these factors, the result can be low-grade meta-inflammation. This culmination of seemingly insignificant stressors can potentially tip us into a pro-inflammatory state, putting us at risk of the wide spectrum of conditions that inflammation is related to. This pro-inflammatory imbalance is what I will refer to as ‘inflammation’ for the rest of this chapter and what can be rebalanced with delicious foods and an enjoyable, healthy lifestyle.

While I want you to appreciate the importance of inflammation as a necessary mechanism in our body, when we examine the triggers of inflammation in modern life using this diagram, it becomes obvious why the balance of inflammation has become skewed towards the pro-inflammatory side of things. This meta-inflammation, as I’ve alluded to, has a role in many conditions including mental health disorders such as depression,⁷⁸ high blood pressure⁸⁰ and insulin resistance which is linked to the development of poor sugar control and ultimately Type 2 diabetes.81, 82 With this in mind, it’s important to try and find effective ways to prevent this imbalance from occurring and the diagram gives us an idea of what we can do to restore the equilibrium.

STOP THE TRIGGERS

The reassuring fact is that we can manage inflammation effectively and simply with changes to what we eat and how we live. It’s not expensive, it doesn’t require excessive interventions or huge modifications and I’m here to guide you through this process. We have many solutions within our control that we can broadly categorise into two steps. The first is to stop the pro-inflammation triggers in the first place. The second is to introduce diet and lifestyle changes to actively reduce inflammation; we possess the ability and mechanisms to purposely reduce the inflammatory response as well.⁸³

The most effective way to STOP inflammation in its tracks is by assessing our diet, which in many cases is the most obvious and clear trigger. Looking at a number of large population studies, the benefits of eating a largely vegetarian diet, from the perspective of reducing inflammation, is undeniable. A number of researchers have demonstrated that eating a western diet made up of refined sugars and carbohydrates, large amounts of animal protein, processed foods and poor-quality fats is related to higher amounts of inflammation signals when measured in the blood.⁸⁴

Conversely, putting more plant foods and fibre in your diet, including good-quality fats that we obtain from nuts and seeds, and eating less animal protein, is linked to significantly lower measures of inflammation.85, 86 Essentially, it is a fairly Mediterranean-style of eating and we can reasonably infer from these studies that reduced inflammation is related to less disease and general health protection.⁸⁵

EXCESS BODY FAT

Fat, also known as adipose tissue, is a very useful part of our bodies that we have required during our evolution. Without fat, we wouldn’t have survived long periods where food was scarce. This explains why those who have a genetic predisposition to putting on fat, particularly around their organs and waists, may have actually been at an evolutionary advantage when it came to harsh winters, famine and lack of nutrition for energy.⁸⁷ Essentially, it would have acted as a storage form of energy that was readily accessible when food was not available.

Today, however, the ability to put on and retain fat is a clear disadvantage considering our current food environment full of ‘convenient’, energy dense and nutritionally poor options. With no famine around the corner there isn’t any use to carry fat on our body and we do not end up burning it for energy. To add insult to the situation, if we do accumulate fat predominately around our organs and waistline, it is ‘metabolically active’. That is to say, it promotes inflammatory signals that can contribute to the burden of diseases we’ve mentioned.⁸⁸ This is why the scientific community promote ‘weight loss’ and reducing ones’ body mass index (BMI) as a strategy to counter the effects of excess fatty tissue.

While I agree that fat tissue is pro-inflammatory and people who lose fat can reduce their inflammatory burden,⁸⁹ a narrow focus on weight alone is sometimes a negative goal for a lot of people who struggle to understand the wider context. I believe health can be independent of weight. It is your lifestyle, mindset and diet that are the biggest determinants of a happy, healthy life. I’d rather you focus on building healthy habits with wellbeing as your main goal, rather than a number on a set of scales. When you adopt a diet that reduces refined sugars and carbohydrates and replaces them with fibre, largely plants and colourful vegetables, coupled with the lifestyle changes I discuss throughout this book, you are lowering inflammation.⁹⁰ These are also the habits that can protect against the dangerous type of fat accumulating around our body’s organs (known as visceral fat) that promotes inflammation and leads to health problems. Before we naively use our scales as a measure of success, I implore you to embrace healthy habits and the subjective measurement of how you feel as a better marker of health.

‘A diverse, plant-focused diet with plenty of fibre and a variety of colours is the easiest and most effective way to support your microbes anti-inflammatory ability.’

SUPPORT YOUR GUT

We are in constant communication with our environment via our digestive tract and so it should come as no surprise that inflammation is heavily influenced by the microbes living in our gut.⁹¹ Our microbiota, the different types of microbes such as bacteria and fungi living mostly in our gut, are important modulators of inflammation. A diverse and healthy population of microbes is associated with lower levels of inflammation and there are a number of mechanisms behind how they achieve this.

Your gut microbes support inflammation balance by increasing antioxidant production and reducing oxidative stress. They maintain the health of the tissues in your digestive tract to lower gut inflammation, which reduces the likelihood of foreign material inappropriately passing into your bloodstream, causing your body to react. Your microbes protect you from infections and improve your ability to control sugar in the blood, plus they actively secrete chemical signals that calm your immune system, preventing an inappropriate inflammatory response. These, and a number of other mechanisms, are why a flourishing, diverse population of microbes is so important from the perspective of balancing inflammation 92, 93, 94, 95, 96, 63 and as you’ll discover as you read on, the most effective way of nurturing a healthy microbiota is with your food.

There is huge scope for introducing specific bacterial strains to counter the ill effects of inflammation, and some studies have had promising results using probiotics (live bacterial strains in supplemental form).63, 97 But, before you reach for specifically designed strains of bacteria that are formulated with ‘anti-inflammation’ claims, let me remind you that your microbiota is best served by a diverse, plant-focused diet with plenty of fibre and a variety of colours. This is the easiest and most effective way to support your microbes’ anti-inflammatory ability.

What follows is a description of lifestyle changes and foods that support your bugs, prevent fat accumulation and balance inflammation through a variety of pathways.

+ Good-quality fats It’s long been thought of as a hindrance to health and wellness to have any fats in your diet because of fears of weight gain and risks to your heart, but once again it comes down to the quality of the fats in your diet rather than purely the amount. Dietary fatty acids from oily fish and nuts can positively impact inflammation by changing the expression of your genes, influencing the inflammation pathways within cells. They’re also the building blocks of molecules that are used to signal your body’s anti-inflammatory response.98, 99, 100 Whole sources of fats from plants such as walnuts, macadamia, pumpkin seeds, sunflower seeds and of course extra-virgin olive oil¹⁰¹ are great sources of fats that have been shown to be anti-inflammatory. These contain more of the Omega-3 fats that can balance inflammation as we learnt about in the chapter on heart health (here). I tend to use olive oil liberally in cooking and I use the highest quality, cold-pressed varieties where possible for flavour as well as function.

+ Polyphenols These are a category of health-promoting chemicals that we find in food and there are literally thousands of them. In general, the coloured vegetables lining our supermarket grocery aisles are great sources of these potent compounds that can target processes related to inflammation. These targets have long and confusing names like the protein complex ‘nuclear factor kappa B (NF)-κB’102,103 and the enzyme ‘cyclooxygenase (COX)’104, which also happen to be molecular targets for medications that we prescribe for things like arthritis and pain. This isn’t to suggest that we can or should replace drugs with food, but the polyphenols you find in a crisp apple, humble pea or vibrant butternut squash all possess the ability to modulate inflammation by impacting these and many other processes involved in inflammation.105, 106 A rainbow diet is the easiest way to guarantee a collection of polyphenols that can lower the inflammatory burden.¹⁰³

+ Green foods Of particular mention are undoubtedly the greens. The impact of brassica vegetables including broccoli, rocket, kale, bok choy and sprouts are absolutely incredible, which is why I try to eat these daily, if not at most mealtimes … and yes, that includes breakfast (try my One-pan Greek Breakfast here or Watercress, Walnut and Crayfish here). These ingredients contain many chemicals, including some well-studied compounds called sulforaphane and indole-3-carbinole that prevent oxidative stress.107,108 These are some of the most technologically advanced ‘drugs’ and they’re only available in grocery stores. Get them on your plate.

+ Red foods Deep red-coloured foods contain a particular type of flavonoid called anthocyanin that is well known to be a potent anti-inflammatory chemical.¹⁰⁹ We get these from cheap accessible ingredients such as red cabbage, blue- and red-coloured berries, chard as well as more exotic ingredients such as black rice, red carrots and purple potatoes. The benefits of red foods are complemented by other colours in your diet. I am by no means suggesting only eating red and green foods for inflammation, but discovering how and why these foods reduce oxidative stress and balance inflammation is exciting enough for me to include these in my diet regularly.

+ High-fibre foods Higher glycaemic index (high GI) foods that release sugar into the bloodstream rapidly are associated with greater inflammation measures in the blood.110, 111 Regular consumption of these high GI foods, such as refined cereals and grains, breads, pasta, cakes and biscuits (no matter whether they are labelled ‘healthy’, ‘wholegrain’, ‘gluten free’, or anything else that has an apparent health connotation) is associated with a higher inflammatory burden. This is not a call to remove these foods entirely from your diet. I would never want to rob someone the pleasure of enjoying delicious freshly prepared pasta or a warm, fluffy doughnut with sticky jam. But, greater awareness of why these are not the best foods to eat regularly will mould your daily choices and heighten your understanding of what health-promoting food means for you. A simple way to reduce inflammation is simply switching from carbohydrates that quickly release sugar into the blood to foods that are higher in fibre and thus release sugar more slowly.¹¹² Examples include split peas, artichokes, onions, whole apples, black beans and yellow lentils. In addition, these foods positively enhance the population of gut microbes by giving them a food source to flourish on.

+ Spices Exotic spices, such as turmeric and cloves, have become a popular topic among those trying to lead a healthier lifestyle. While I welcome greater research into the exciting compounds found within these spices, especially as they may have a role in treatment of inflammatory disorders such as osteoarthritis, psoriasis and rheumatoid arthritis,113, 114, 115 they are by no means the only ones. As a general rule of thumb, a wide range of spices contain dense concentrations of phytochemicals and micronutrients, which provide a variety of antioxidants that have the potential to reduce inflammation.116, 117 Rather than concentrating your diet around specific spices that you may not even enjoy or have access to, a simple strategy is to use those that you appreciate the flavour of. You’ll notice all of my dishes use plenty of spices and herbs and there is a clinical as well as culinary reason behind this. I’ve purposely included a section dedicated to making fresh pastes and spice blends from scratch (here) and I hope they will encourage you to enjoy the process of using these amazing ingredients, ranging from mint, basil and marjoram to sumac, cinnamon and cayenne.

LIFESTYLE 360

These changes to the diet can serve to improve our balance from a state of pro-inflammation to one that is more harmonious with the intended function of our bodies. Your lifestyle, however, is important and these practices are just as impactful.

+ Slow down your eating I used to find myself running from appointments across the city with a snack in my hand, eating at my desk to sift through mounting paperwork during clinic or squeezing meals into a 10-minute break on an A&E shift. Many of my colleagues and patients relate to this. Even when we’re not rushed, we eat in front of screens, we scoff food at pace and hardly ever take time to appreciate the ingredients themselves. A measurement of stress in the body is a hormone called cortisol that is shown to be lowered if food is eaten slower and more mindfully.¹¹⁸ The state in which food is consumed can be just as impactful on the body as the food itself. As a simple practice, I recommend patients take a few gentle breaths before starting to eat, and remove screens, in an effort to slow down the process so they can give their full attention to the food and perhaps the conversation around them.

+ Mind–body interventions Mind–body interventions, like Tai Chi and meditation, have been shown to reduce the expression of genes which code for proteins that lead to inflammation.¹¹⁹ In many studies, different types of stress-relieving and relaxation techniques have demonstrated significant anti-inflammatory effects.¹²⁰ There should be no doubt that stress and psychological ill health are associated with inflammation and, conversely, stress-relieving techniques are anti-inflammatory.¹²¹ When appropriate I discuss these studies with patients and I find that describing the clinical research underpinning my belief in the utility of mind–body interventions is really motivating for them. Think of mind–body interventions as any practice that encourages inner calm, whether that be the simple act of reading in a quiet space or meditation and yoga practices.

+ Walking If the thought of joining a yoga class or even deep breathing is too overwhelming, you’ll be pleased to hear about the mountains of research that consider the effectiveness of simple walks in nature. The Japanese practice of ‘shinrin yoku’, which literally translates as ‘forest bathing’, has a large body of evidence examining the physiological as well as mental health benefits of this practice.122, 123 Along with a reduction in heart rate, blood pressure and improvements in mood, forest bathing practices have reduced laboratory measures of inflammation such as cortisol and inflammatory proteins measured in the blood. Taking yourself to a park or forest at least once a week for a relaxing stroll could be one of the most hassle-free and effective ways to reduce your inflammatory burden without having to adjust your diet or do much at all.

‘If we can harness the incredible effects of not only our food, but the anti-inflammatory potential of our lifestyle, we could drastically reduce the problems that excess inflammation poses to our health.’

+ Sleep Given the number of homeostatic mechanisms that occur during sleep, it’s unsurprising that even a single night’s lack of shut-eye increases inflammatory signals in the body.¹²⁴ During sleep our blood pressure lowers, our temperature drops and levels of rejuvenating hormones like melatonin, which have powerful antioxidant effects, rise to their highest levels. As told in exceptionally certain terms in his book Why We Sleep, the sleep medicine expert Professor Walker has warned that a lack of sleep puts us at greater risk of diabetes, cancer and cardiovascular disease. It’s often noted that people with high inflammation, as a result of conditions such as arthritis, diabetes or obesity, often have disturbed sleep. It appears that inflammation and the proteins that signal inflammation have an interconnected relationship to sleep and may even regulate our need for slumber.¹²⁵ The advice for now is to at least allow yourself the opportunity to enjoy about 8–9 hours of rest per day. Put your electronic devices away a couple of hours before bed, eat early if possible and give yourself potentially the best dose of anti-inflammatory medication available to us.

If we can harness the incredible effects of not only our food, but the anti-inflammatory potential of our lifestyle, we could drastically reduce the problems that excess inflammation poses to our health. What this chapter represents is a medicinal package for many patients without the need for strong drug interventions. We will always need pharmaceuticals and as a doctor I do not hesitate to use them where appropriate. But the primary consideration should always be what we put on our plates and the way we live. These should be the first therapeutic interventions before we entertain more invasive measures that can carry a greater risk versus benefit.

Eat for

Immunity

The purpose of this chapter on immunity is to get you thinking about immune health in a different way. Rather than thinking of immunity as an isolated system that requires ‘boosting’ with individual ingredients, think about it from the perspective of making healthy lifestyle choices to build your metabolic and energy reserve. This strengthens all of the specialised cells and organs needed to support your body’s natural immunity and homeostatic mechanisms.

Your immune system is a collection of proteins, organs and parts of the body that work in unison to protect us from harm. This includes everything from the acid found in your stomach to prevent harmful bacteria invading your gut, to the thick protective protein layer of your skin that physically keeps harmful microbes out. Immunity also includes the complex network of specialised cells that work in superb coordinated sequences to maintain the harmony of your internal ecosystem.

We need a resilient immune system to protect us from infective organisms like viruses and bacteria, but we also rely on this complex network to protect us from the malfunctioning of our own cells. Immunity is traditionally thought to be just our defence system, protecting us from harmful microbes that live in the external atmosphere, but it also ensures the correct functioning of our internal environment. Our immune system is responsible for identifying and appropriately clearing away mutated or malfunctioning cells that can lead to, for example, inflammation and uncontrolled growths that can become tumours.

Trillions of times a second, chemical reactions are occurring in your body and as a product of normal metabolism and sheer probability, some cells are created that are malfunctioning or damaged.126, 127 In addition, normal radiation from the sun or environmental pollution from smoke inhalation can also damage your skin and lung cells respectively and this needs to be dealt with. We rely on our body to clear these damaged cells effectively, so they don’t lead to further negative effects. This is the job of our wonderful immune system. It is what we depend on to carry out these processes and it does so with beautiful precision and efficiency without us having to think about it.

The wonderful thing about our immune system is that it is everywhere. You might think of our detoxification system as our liver and kidneys, or our mental activity centre as our brain, but our immune system has to be prepared to step into action at any site in the body. Whether it’s to protect us from a skin-cut to the leg that could be an entry point for bacteria invading the bloodstream, or recognising a malfunctioning cell in an organ and clearing it away so it doesn’t develop into a growth, your immune system is ready.

I hope this gives you a broad idea of the magnitude of immunity and why simply eating or medicating ‘to boost’ it is a misnomer. I appreciate it’s a nice idea and an easy-to-understand concept; you eat something, it ‘boosts your immunity’ and you become a common-cold-kicking superhuman. But in reality, our bodies do not work like that. Our vast interconnected systems of cells do not simply respond to one element like Echinacea or zinc. It is called your immune system because it is an incredibly complex network of cells that require balance and harmony, and for this reason alone I hope you can already appreciate that there is no ‘silver bullet’ nutritional supplement or pharmaceutical product that magically improves your immune health.

GUT HEALTH

There are particular sites in the body where immune cells interact with each other and are developed, including the bone marrow, the spleen in your abdomen and lymph nodes dotted around your body such as the neck and groin. Of particular anatomical significance, however, is our gut. Our digestive system is the closest contact to the outside world. Everything we eat and drink from our environment is covered in microbes and we have been in constant communication with them in our environment throughout our evolution via this 30-foot long tube. But rather than being fearful of them, it’s important to realise that most of the microbes that live in our digestive tract are integral to our health. Our microbiota, the population of microbes including viruses and fungi but predominantly bacteria, are mostly situated in the large intestine. As we have discussed, this huge population of foreign cells is responsible for digesting food, releasing vitamins from ingredients and maintaining our health¹²⁸ (see here). The lining of the gut has to be super thin so the products of digestion and metabolites from gut microbe activity can pass through into the blood in order to be transported around the body.

The thin gut lining facilitating transfer of nutrients is necessary, but it’s also a route for harmful microbes and products to pass into our blood which could lead to damage, therefore our immune cells need to be constantly assessing and recognising friend from foe in these areas. It is relentless work to keep our human cells in harmony with foreign microbes, as well as detecting which of these organisms we need to get rid of. This is why so many immune cells are concentrated in our digestive tract and it explains why the gut has the largest amount of ‘lymphoid tissue’ that contains cells of the immune system.¹²⁹

So, instead of simply using the analogy of an aggressive military force to describe our immune system, I like to see our immune cells as having just as much of a peacekeeper role in the complex world that is your human body. This is because the majority of cells contained within the body don’t actually belong to us. Microbial cells outnumber our own human cells and our health, particularly our immune health, depends on us keeping this population of microbes thriving. This objective is best served with a diet and lifestyle that nurtures them.

Having a robust and well-functioning gut population protects and bolsters our ability to deal with infections on several levels. Specific gut microbes maintain the integrity of the gut wall, preventing harmful pathogens or materials inappropriately entering the bloodstream. They secrete their own antibiotic and anti-fungal chemicals that attack harmful microbes, preventing them from colonising the gut. Beneficial microbes support an anti-inflammatory environment, which again is why good gut health improves cardiovascular disease and diabetes. The microbes themselves produce and release micronutrients that support our immune cells as well as protecting us from harmful environmental toxins.¹³⁰ Keeping our microbiota in shape improves our immune health and involves eating colourful vegetables, fibre and a wide variety of whole foods. Dishes such as the Ethiopian Berbere Curry (see here) or the Pea Orecchiette (see here) are great ways to achieve this.

AUTOIMMUNITY

Because of a general recognition of the importance of the gut microbiota in immune-related diseases, researchers are increasingly looking at gut-focused treatments for problems related to imbalances in our immune system. Sometimes our immune cells can inappropriately send signals to fight infection or attack normal human cells that are perceived as foreign. This is a simplified explanation of autoimmunity which is different to something like hay fever or dust-mite allergy, which is an exaggerated immune response.¹³¹

It’s recognised that those who suffer from autoimmune conditions including psoriasis and rheumatoid arthritis tend to have imbalances in their gut populations.¹³² The research is still in its early stages but we also recognise that those who suffer from exaggerated immune responses, like in the case of asthma and eczema patients, may lack certain populations of gut bacteria that harmonise the body’s immune response.133, 134 This has led to the hypothesis that repopulating the gut microbiome with beneficial microbes may improve symptoms.

A theory gaining popularity to explain one of the causes of some autoimmune (AI) diseases is that the immune cells have been exposed to products that have entered directly into the bloodstream via ‘gaps’ in the lining of our digestive tract.¹³⁵ These products have not been properly processed and identified by the immune system cells within the gut, and thus trigger an aggressive response that leads to harm of the normal tissue. It’s still under a lot of debate but it’s interesting to note that gut-focused treatments for AI disease, where potential triggers have been removed allowing the gut wall to repair itself, have led to some remarkable results.136, 137 I don’t have the space to dive into a full discussion of such a nuanced topic in this cookbook, but there is some interesting research on the horizon as well as a lot more we have to learn about process behind AI conditions and therapeutic dietary strategies. I suspect that it is more complicated than just nurturing the microbiome, but ensuring a healthy and thriving gut population using food could be a good starting point for helping with these illnesses and a lot of well-respected scientists in the field are in agreement on this.

ELIMINATION DIETS

It’s my responsibility to be honest about the validity of these interventions and assess whether you could benefit from them. There has been a lot of speculation regarding AIP (autoimmune protocol) diets and, although these appear to be restrictive and eliminate perfectly healthy items from your food, there have been some interesting and significant outcomes gained from their use. Depending on the condition, these short-term therapeutic dietary interventions may be beneficial, but I hasten to add that they should be actioned with the guidance of an experienced practitioner. I’m mindful of the scaremongering tactics surrounding components of food: gluten in flour, lectins in beans and other common ingredients. My advice is to maintain a high suspicion of anyone blatantly brandishing a single food as harmful for everybody and making outlandish and unhelpful claims. It makes no scientific sense to suggest gluten is bad for all citizens of the UK, for example, and I discussed the many reasons behind this in my first book. But I do believe there is a case for some patients to trial dietary strategies and many rheumatologist and immunologist colleagues are starting to use them carefully with interesting anecdotal successes.

MITOCHONDRIAL SUPPORT

In recent years, we’ve also begun to recognise the profound importance of a component of our cells called mitochondria. These are found in all of our cells and have been traditionally referred to as the ‘powerhouses’. These incredible batteries provide energy for all normal cell functions, but they’re also critical for recognising when an immune response is required.138, 139 Cutting a longwinded biology lesson short, we require healthy, functioning mitochondria for a robust immune system that can boost its metabolic activity to adapt to the increased demands of when your immune system needs to be more active. Whether it’s fighting an infection or balancing oxidative stress, your immune cells require more energy, and mitochondria are key to this. Supporting your mitochondria by preventing damage and providing them with fuel is therefore an essential immune-supporting strategy. Things that damage mitochondria include high-sugar diets and stress, and this gives us one explanation as to why poor diet and mental pressure appear to have detrimental impacts on our immunity.¹⁴⁰

This is a very new area of research, so the evidence base behind what to eat for mitochondrial support is lacking, but that shouldn’t stop us from being able to make reasonable, educated adjustments to our lifestyles that we can be sure are safe. Even if we cannot accurately determine that they are specifically supporting mitochondria, they are certainly beneficial to your body in many other ways.

However, diet related to immunity is a difficult topic to tackle. Unlike cardiovascular disease or diabetes, there aren’t many studies examining the effects on immunity nor biomarkers that we regularly test to check someone’s immune capacity.¹⁴¹ However, the suggestions below encompass the entire ethos of this book: to give you reasonable evidence-based suggestions, with a good dose of common sense, about how your lifestyle can enhance the functioning of your incredible body. These delicious ingredients will get you thinking about how nutrition is exceptionally important to building your immunity.

‘There are added benefits of obtaining vitamin C plus the abundance of other vital micronutrients from whole foods rather than supplements in isolation.’

+ Orange, yellow and green foods Bright orange and yellow-coloured foods, including winter squash and sweet potato as well as dark greens such as kale, contain vitamin A precursors called carotenoids. These plant chemicals are essential to our immune system and have a role in maintaining our gut barrier, the functioning of specialised immune cells as well as the cells involved in the immediate response to stressors.¹⁴² We also find different sources of vitamin A in animal products such as fatty fish and organ meats we don’t tend to consume much of, such as liver. Try the Fennel Sardines with Pine Nuts (see here) or the White Beans, Butternut Squash and Spicy Couscous (see here).

Along with vitamin A, brightly coloured foods also contain vitamin C, as do a number of green vegetables including broccoli, parsley, spring greens and Brussels sprouts, and by lightly steaming them (a technique I use regularly in my recipes) we can maintain this vitamin content. It’s long recognised that vitamin C is important for immune cells.¹⁴³ It can aid your ‘first response’ immune system activity and vitamin C itself is a strong antioxidant which is important to protect your immune cells and limit the oxidative stress within your mitochondria.144, 145

For these reasons, many of my patients have bought into the advertising for vitamin C supplements. Although I believe these are fairly safe and well tolerated, there are added benefits of obtaining vitamin C plus the abundance of other vital micronutrients from whole foods rather than supplements in isolation. There are a huge range of other nutrients contained in dark leafy greens and citrus fruits beyond just vitamin C. For instance, a pile of steamed greens with olive oil, salt and lemon (like my Horta recipe here) would be a fantastic accompaniment to most meals as it doesn’t just offer vitamin C; it delivers sulforaphane, magnesium and added fibre to your diet. I encourage people to think of their food as a wonderful collection of thousands of micronutrients and plant chemicals rather than just one or two vitamins.

+ Nuts and seeds Nuts like cashews, almonds and Brazil nuts, as well as sunflower seeds and flaxseed, contain good sources of zinc, selenium and vitamin E. These three micronutrients have individually been studied in clinical trials using larger doses than found naturally with some positive results on immune health, which is why they’re labelled ‘immune boosting’ in many stores.146, 147, 148 However, I believe using supplements of individual micronutrients in large quantities is for the majority of people unjustified. Certain populations who may be at risk of deficiency and have lowered immune health, such as the elderly, may benefit from supplemental forms but we can obtain reasonable amounts of these essential nutrients from wholesome, delicious food. Not only do I use nuts and seeds to add texture to food, but they’re fantastic sources of protein and fibre that additionally contribute to immune health. Try the Herby Walnut and Cashew Roast (see here) for a great way of using more quality fats.

+ Fibre An effective strategy to improve our immune system would be anything that helps our gut environment; specialised prebiotic fibres including chicory, endive, Jerusalem artichoke and garlic provide your microbes with a source of food. When digested, they’re able to make a fatty acid chemical called butyrate which helps maintain the lining of the gut wall.¹⁴⁹ A well-fed microbiota is better equipped to carry out its immune-modulating role of reducing inflammation and preventing pathogenic microbes from colonising in the gut, causing ill health.

+ Herbs and spices A variety of vegetables, like the colourful ingredients described above, also provide a fantastic food source for the microbes and there is also a rationale for using plentiful herbs and spices. Ginger, turmeric, fennel, and some botanicals like peppermint may have a role in immune support as they have been shown in some small studies to reduce gut inflammation.¹⁵⁰ I think regularly including herbs and spices in our food for a culinary as well as functional purpose is an important aspect of our diets that we should embrace. Try the Ras el Hanout (see here) or the Laksa Paste (see here) for ideas.

There are some specific botanicals and herbs that have shown ‘immune modulating’ capacity, in that they may stimulate the production of cells of the immune system.¹⁵¹ There is also a tradition of using different herbs for immune support across many cultures, including elderberry, Echinacea, mushroom varieties and probiotics. However, I would rather we focus on accessible diet and lifestyle aspects that serve to build your immune reserve rather than relying on immune-modulating plants for general sustenance. Improving your lifestyle and diet are much more powerful strategies than relying on a special flower or fungi for support.

LIFESTYLE 360

Nutrition has a huge role in maintaining robust and balanced immunity, but if there was any system that exemplifies why total coordination of lifestyle factors, such as exercise and sleep, is necessary for universal functioning, your immune system is the poster boy. By harnessing the power of a variety of lifestyle factors, you can greatly enhance your metabolic energy and the ability of your immune system to perform at its peak. It will not only improve your resilience to common viruses and pathogens, but also aid inflammation balance under the control of immune cells.

+ Exercise For everyone there is an exercise sweet spot. Regular moderate exercise has been shown to universally benefit immunity. Aerobic exercise actually encourages your body to be more resilient to stressors and therefore has an overall benefit, despite the short-term effects of exercise being inflammatory.¹⁵² Aerobic exercise can actually improve your mitochondrial function which may also be why regular exercise builds a resilient immune system.153, 154

Persistent over-training, however, is associated with reduced immune reserve. There are recognised health risks of putting high amounts of strain on your body by over-exercising, that researchers have observed in endurance athletes like cyclists.¹⁵⁵ A balance of training is what we should be aiming to achieve and there are specific types of exercises that may be particularly good for immune health.

+ Yoga Described as both a mindfulness technique as well as a form of exercise, recent studies on yoga have examined a fascinating effect on immune cells.¹⁵⁶ Researchers have demonstrated that yoga practices can impact the expression of genes to one that positively improves immune cell function. Similar effects have been shown with other practices such as Qi Gong and Tai Chi.¹²⁰ Combined with the physical benefits of the exercise, yoga could be one of the best all-round immune health promoting activities we know of. The best advice I have is to mix it up. I have developed my own yoga routine from watching online yoga sessions that are very accessible and easy to follow, as well as attending classes now and again to get some pointers. But I would also encourage HIIT (high intensity interval training) sessions, too, to improve aerobic capacity, as well as endurance training such as cycling and swimming for their additional benefits.

+ Meditation The gradual deterioration of our immune capability as we age, known as immunosenescence, may be closely related to both psychological distress and stress hormones.¹⁵⁷ It would stand to reason that techniques to reduce stress effects may be beneficial from an immune perspective. Combined with the many positive effects of mind–body interventions, practices such as deep breathing, transcendental meditation or simple walks in nature are a no-brainer for me to advise. I was pleased to read a paper about the positive effect of walking in nature, specifically on cells of the immune system.¹⁵⁸ So perhaps the most immune-system-enhancing of activities could be a yoga session in a park followed by deep breathing in natural sunlight. And this brings me nicely onto the subject of vitamin D.

+ Vitamin D More than a vitamin, vitamin D acts as a master hormone that regulates a multitude of genes involved in a huge number of processes. Beyond its well-recognised involvement in bone health and calcium regulation, vitamin D has a very important role in immune health.159, 160 In both the initial ‘innate’ response to infections and the more specific ‘adaptive’ responses, scientists are researching the role of vitamin D and its importance to auto-immune conditions. There are very few sources of vitamin D in the diet and thus medical practitioners in the UK have taken to recommending vitamin D for the whole population during winter months and for those with darker skin colours. The best advice is to get adequate sun exposure outdoors, have regular tests by your GP if you’re at risk and take a supplement during the darker months of September to March in the UK.

+ Sleep deprivation It will come as no surprise to many people that sleep deprivation drastically lowers a person’s immunity. Your immune system is very likely to be regulated by routine and the sleep–wake cycles which influence all other cells in your body operating on a rough 24-hour cycle.¹⁶¹ This is why sleep is integral to a healthy immune system. As a GP, I’ve lost count of the number of people turning up on a Monday suffering acute tonsillitis directly attributable to late nights at the weekend or travel. But this is just the tip of the iceberg. Persistent sleep loss significantly disrupts your immune system, increasing inflammation which drastically raises the risk of chronic illnesses like heart disease, Type 2 diabetes and even cancer. As you can probably appreciate by now, these are all conditions related to an ill-performing immune system. Achieving 7–9 hours of sleep a night could be considered one of the most potent therapies for improving ones’ immune system and it’s definitely on my prescription pad.

To sum up diet and lifestyle strategies to improve immune health we simply need to remember a few facts: gut health is exceptionally important; there are well-recognised detrimental effects of a western diet on immune health¹⁶² (high in sugar, refined carbohydrates, low in fibre and lacking in micronutrients); certain micronutrients are critical for the adequate functioning of our immune cells; and the importance of supporting our mitochondria cannot be underestimated. Although this may sound complicated, the reality is that these additions to your diet and routine are accessible and straightforward. I’m confident that it is achievable for you as it is for many of my patients and my recipes will set you on the right path.

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