Saturday, 12 January 2019

New year, new me: Lose weight, exercise and have more 'me time'

As we have now left another year behind and trying to ease ourselves into 2019, we are all motivated to think what we want from this brand new year and plan achievable goals. What with magazines, tv programmes and social media channels covering new year resolutions such as losing weight, joining to gym and getting your finances sorted, and advertising industry bombarding us with offers on discounted gym memberships, weight loss clubs and even elective-surgery to make us look 10 years younger, what choice do we have but reconsidering the cancellation of the direct debit to the gym membership we have not used since January 2018?

Well, for one, I thought to myself that this year I will not give into the social pressures and will not renew my gym membership -which I had for the past five years and used it about five times-. Don't get me wrong, I would love to be one of those people (e.g. my husband) who enjoys going to exercise classes and workout indoors, and can commit to doing so at least twice a week to make the membership count. But I am not. I am not going to make excuses such as 'I would love to but I don't have time' as I know that the gym is literally five minutes walk from my house and if I really wanted to I could easily make time for it. The truth is, I rather be indoors, curled-up on the sofa with a good book or walking outdoors with my dogs / touring the countryside with my bike, admiring houses I can't afford to buy. As someone living with arthritis, my default choice will always incline towards the sofa option. But I also know -and should know as a clinician and health researcher- that I need to increase my physical activity levels to cope better with pain and fatigue, as well as keeping fit and managing my weight. The recommended guidelines for physical activity suggests, to stay healthy or improve health, adults need to do 2 types of physical activity each week: aerobic and strength exercises.

Physical activity guidelines for adults 

How to remain/ become more active with arthritis?

So, how do we go about having more realistic goals towards increasing our physical activity levels if we are living with arthritis and not inclined towards wearing lycra in front of mirrors in public? The answer is simple, do something you enjoy, do it regularly and do it in manageable chunks, being kind to your body. The trick is, not do get too excited and over do it. You probably have done that before. You know, perhaps you were having a good day and over did it and then ended up hurting so much the following day, it put you off doing it again? I know, I have been there. In fact, this is how we develop exercise intolerance or a 'can't do' attitude. I see it all the time in my clinical practice, people say that they used to love doing gardening, but can't do it anymore.. or that they used to hike, but don't do it anymore as they don't have the stamina. The fact is, they actually CAN but just CAN NOT do it the way they used to do it. Or, some people are simply too worried about doing more damage to their joints. First of all, let me assure you that you can do more damage to yourself by doing nothing. Sedentary life styles leads to muscle loss, weight gain and decreased fitness. Sitting for long periods is thought to slow the metabolism, which affects the body's ability to regulate blood sugar, blood pressure and break down body fat. This includes watching TV, using a computer, reading, doing homework, travelling by car, bus or train but does not include sleeping. So it is really important that we at least maintain our physical activity levels, and ideally increase it, if we want to see real benefits.

Coming back to gardening, yes, you may not be able to trim down all your hedges at once and lay your flower bed in an afternoon. But can do it over a longer period of time with some sensible planning and careful adjustment as to how you go about doing it without compromising your joint integrity or energy levels. I understand that garden tools can be hard on aching hands and going down on your knees may not even be an option anymore if you are struggling with knee/ hip pain and problems. But, if there is a will, there is a way. None of us have to give up on things we love and enjoy, especially if they have additional health benefits. Rheumatology occupational therapists can help you to participate in activities you once treasured, by making tailored recommendations towards how to change the way you do things to keep active and achieve a healthy balance between daily activities, work and leisure. You can also access to written self-help information freely available on leading arthritis charity websites, such as the Versus Arthritis and NRAS on how to remain active, stay at work and manage common symptoms of arthritis. There is a wealth of self-help information out there to help with other important things too, such as sex and arthritis as pain and fatigue may reduce your enjoyment of sex and other activities and interests that you share with your partner.

So, my new year resolution for increasing my physical activity levels are to take my dogs out for longer daily walks, do daily stretching and strengthening exercises at home to manage pain, and perhaps most importantly to have regular 'me time' to look after my psychological wellbeing by doing more mindfulness and relaxation. Mindfulness practice involves giving the mind and body the space to relax, acknowledge and release feelings about pain or other challenges, let go of tension, and tap into a positive outlook. Research evidence supports that focusing on negativity exacerbates our pain and fatigue. Mindfulness practice can allow you to step back from the cycle of negative thinking and provide an opportunity to be more present in the here and now.

There are countless free resources available on the internet to help you understand how and where to start to practice mindfulness and take a mindful approach when interacting with other people and the environment that may challenge our inner peace. Here is a brief how to guide for people with arthritis.

So, don't sit there. Get up and potter around the house, go up and down the stairs, do some stretches. The less you sit still, better your pain and fatigue will get, and you will notice significant changes in your joint stiffness too. If you are still unsure whether to exchange your comfy sofa for a walk, I suggest you spend five minutes to read about the 'sitting is the new smoking campaign' here. Did you know that you burn on average of 50 calories more per hour by standing? Standing up for 3 hours/ day, five days/ a week adds up to 750 calories burned. In a year that adds up to 30,000 calories, which is equivalent of 9 pounds in weight! So, what are you waiting for?

Wednesday, 7 November 2018

What is your gut telling you?

Did you know that your gut is practically your second brain? Yes, indeed the enteric nervous system is often referred to as our second brain and it houses a complete ecosystem of microbiome [a diverse range of bacteria, yeast, parasites, and other single-celled organisms that live in and on our bodies] which is unique to us as our fingerprint. The gut also lined with a vast neural network comprises some 100 million neurons. To put this into perspective, our gut has more neurons than our spinal cord and it gives more information to our brain than it receives. So, our gut is not only the main portal to our external environment, but also runs the complex procedures such as processing food, absorbing nutrients, dealing with infectious agents and toxic substances and finely tuning our immune system pretty much by itself. Ok, our gut is not our thinking brain, it does not help us to pass an exam or to multi-task, but there is a growing evidence to suggests that our gut strongly influences how we feel. I am not simply referring to times that when we feel bloated and uncomfortable, and therefore not in the mood; the gut–brain axis  -the biochemical signalling that takes place between the gut and the central nervous system (CNS)- is so sophisticated, changes in the composition of the gut flora causes changes in levels of circulating cytokines, some of which can affect brain function. Cytokines act through receptors, and are especially important in the immune system. Considering the fact there are at least 80 types of autoimmune diseases such as Rheumatoid Arthritis (RA), Inflammatory Bowel Disease (IBD), and Systemic Lupus Erythematosus [SLE], which are commonly chronic, debilitating and sometimes disabling, it is about time that we start to pay attention to what our guts are telling us. 

Because our gut is so sophisticated and interconnected with our entire body, multitude of factors can affect its balance. If our lifestyle choices lead to stress and anxiety, poor dietary habits, illness and sedentary behaviour, which we often try to fix with taking cocktail of drugs, these can lead to abdominal pain, bloating, nausea and vomiting, indigestion, constipation, diarrhoea and flatulence (wind). Moreover, we know that the gut produces more than 90% of the body's serotonin, a hormone that helps regulate our mood or emotions. If the gut is not functioning well, regulation of such vital hormones are also affected. To cut the long story short, if our gut is not happy, it is unlikely that we can be happy and contented.


As an arthritis sufferer, health professional and a rheumatology researcher I have always been fascinated by the role our gut plays in the symptoms of arthritis, such as pain, fatigue, low mood and unrefreshed sleep. As I specialised in self-management and patient education, I made a point of talking about healthy eating and what that is look like to my patients and students. Nevertheless, like the majority of my patients, over the years I have started to carry on extra weight around my abdomen (which suggests visceral fat, stored around a number of important internal organs such as the liver, pancreas and intestines) that did not help my pain and fatigue levels.

Of course, I tried to look after my diet and eat clean; I stopped eating red meat 20 years ago, and ate chicken and fish in moderation, so my diet mostly consisted of green leafy vegetables, whole grains and fruit. But more often than not I had given in to sandwiches and cakes laid around in work meetings and conferences and nibbled on late-night snacks of peanut butter sandwiches and crisps. I had that ‘second wind’ in the evenings [no wonder] where I could work until the early hours of the morning, and then go to work in the morning wondering why I have chronic widespread pain and fatigue. It’s not that I did not know that my lifestyle was aggravating my condition, I did. But like everybody else I was the victim of my own habits and comfort zone - made excuses for myself such as ‘I am a night owl, I am just more productive at night’ or ‘I will sleep when I die’ and for late night snacks I simply convinced myself that staying up late meant I needed sustenance! I knew I needed to exercise more, but I neither like the gym nor I had the time for it, hence the only real exercise I did was walking my dogs, which I frequently found more exhausting than it should, having spent all my energy on working and not sleeping. The trouble is I love my work, so I never really give it a second thought that I should work less.


At around six weeks ago, I watched a documentary on Fasting whilst travelling back from London on the train.  I knew about fasting already and have briefly tried the 5:2 intermittent fasting previously, failing miserably as I couldn’t cope with going without food all day. As I knew the science behind fasting, the associated health and longevity benefits, I wanted to watch this documentary out of interest. Those who knows me well will know that I am obsessed with non-fiction books, audiobooks and documentaries, so it was just something to do whilst travelling on the train to avoid motion sickness. The documentary explored 7 different methods by the world's leaders of fasting. I really enjoyed the film and was particularly fascinated with the 16:8 intermittent fasting method which seemed easy to do yet very effective. This type of intermittent fasting involves limiting consumption of foods and calorie-laid beverages to a set window of 8 hours per day and abstaining from food for the remaining 16 hours. This cycle can be repeated as frequently as you like, from just once or twice per week to every day, depending on your personal preference. In addition to weight loss, 16:8 intermittent fasting is also believed to improve blood sugar control, boost brain function and enhance longevity. It is said to cause insulin levels to drop, which improves insulin sensitivity, optimises blood sugar levels and burns fat. Plus, short-term fasting has been shown to induce an important cellular repair process that helps remove waste and toxins to keep your body healthy. Many people prefer to eat between noon and 8 pm, as this means you’ll only need to fast overnight and skip breakfast but can still eat a balanced lunch and dinner, along with a few snacks throughout the day. Skipping breakfast was not an issue for me, as I hardly ever had any [probably something to do with late night snacking]. However, you can experiment and pick the time frame that best fits your lifestyle. It is also suggested that, to maximise the potential health benefits of your intermittent fasting, it’s important to involve nutritious whole foods in your diet.


I decided to have a go at this, purely due to its simplicity with a hope to stop my late-night feasts. I bought a NutriBullet to make delicious smoothies to increase the nutrition value of my food intake and started to take pack lunch to work, so I was not tempted by the fast food options.
I have decided to eat between 10am and 6pm as this meant I skip breakfast, eat a normal lunch and just have an early diner at work. I must admit, the first week I struggled a little bit at night, as past 9pm I was getting peckish and rather resentful of my teenagers’ constant snacking throughout the evening. My husband has been very supportive and said that he will also try to fast 12 hours over night, despite being very healthy and not having any weight issues, he was also attracted to the health benefits of fasting. Interestingly, being hungry at night made me go to bed early to avoid picking on food. Before I knew, my sleep got into a better routine, so I was not as tired during the day. After the first week the fasting started to get so easy, I started going 18 hours in average without food instead of 16 as naturally I was stopping to eat earlier around 4pm. After two weeks I started to notice real difference in how my clothes fit better and my skin started glowing. Prior to this, I had almost frequent headaches, which sometimes turned into migraines or cluster headaches for days. I did not have a headache in the last 3 weeks, my joint pain is significantly reduced, and I feel actually energised first time in years other than the times I have been on steroids. I also sleep better, going to bed approximately the same time every night and waking up at the same time each morning. Consequently, I think I am a nicer person to be around with, as I generally feel in a good mood. Although 4-weeks is relatively a short time to start thinking about its long-term benefits, I can honestly say that I feel I have finally found something that works for me and I anticipate that it will continue to work in the future as it is so easy to do and the benefits are so worth doing it. I have been doing the intermittent fasting every day, but the evidence suggests that taking the weekend off has no impact on the long-term health and weight-loss benefits. Talking about weight, so far, I lost 4cm off my waist, which means visceral fat loss. So, I am a happy girl. But I am most certainly more impressed with the impact this way of eating made on my arthritis symptoms. As a result, I am doing more, longer walks with my dogs and sleeping better.

Last weekend we went to the movies as a family and I had my usual nachos loaded with cheese and lots of jalapeƱos. This was followed by a visit to the TGI Fridays (kids’ favourite) and having been eating clean for weeks I thought I will treat myself to fried fatty food, despite not being hungry at all. I ordered a starter portion, but still was unable to eat it all. It was not long after I knew that this was a big mistake, as my second brain (the gut) did not concur with my thinking. I had the worse indigestion and back pain all night and was unable to sleep first time in weeks until after midnight. It just brought home to me, how quickly my gut got used to the good life and rejected the ‘bad food’ and how punishing it was to go against it! I don’t think I will be making that mistake anytime soon. I think finally I learnt to listen to my gut. Maybe it was trying to talk to me for years and I have learnt to ignore the signs. But I now hear it loud and clearly. So, I wanted to share my experience with everyone, and especially with those who suffers from chronic pain and fatigue. What is your gut telling you? If you can’t hear its voice, or if it is crying out with the symptoms of irritable bowel syndrome, and keeping you up at night, maybe you could consider intermittent fasting to see if it will make a difference to your symptoms? Please note, if you have a health condition and/or you are on medication, I strongly advise that you should consult with your GP prior to starting this regime to ensure that you can safely undertake it.

You can find more information on intermittent fasting here.

Friday, 28 September 2018

Making Arthritis My Job

Living with arthritis

I feel as if arthritis has played a part in my life from an early age. I was diagnosed with Acute Rheumatic Fever soon after my 7th birthday. I remember coming back from summer holidays, where I spent the majority of my time by the seaside; swimming, playing on the beach, building sand castles and getting sun burnt. Par my return home, I had streptococcal pharyngitis and couldn't get out of bed for the rest of the holidays. This was followed by various red spots and bruises appearing around my knees, ankles and foot, which were tender and painful to touch, so prevented me from walking.  Following a series of visits to various doctors and specialists, my treatment involved using long-term antibiotics to avoid recurrent infections to prevent progression to rheumatic heart disease. I have had monthly penicillin injections at a local Italian Hospital in Istanbul for years to follow. It stung and temporarily numbed my lower limbs, causing me to limp for the rest of the day. Which was not the image I was trying to portray at the school! The distinct scent of the antibiotics etched into my memory to this day, and I used to get anxious when entering to a pharmacy until my late teens, as I come to associate the scent with my traumatic visits to the hospital. On the upside, we have always stopped by the fancy stationery shop by the hospital afterwards and I was allowed to buy a nice pencil or a scented eraser to stop me feeling sorry for myself.

Since then, I have been diagnosed with other types of arthritis to include  Juvenile Idiopathic Arthritis, Undifferentiated Spondyloarthritis (USpA), Osteoarthritis and Fibromyalgia. All of which had common symptoms of widespread chronic pain, fatigue, sleep difficulties and dyscognition. I have learned that arthritis was here to stay and if I were to have a 'normal' life, I had to learn to live with it. So I continued my life, pursuing my goals with a sense of resolve to not give in, by adapting the way I did things as and when it tried to stop me on my tracks, developing my own self management strategies as I go.

Making arthritis my job

Like most people, I have not come to recognise my true calling upon leaving the school aged 17, and spent 10 years in training and working in the IT field, initially in Turkey and later in the UK. At the age of 25 I have already had two children under the age of two, and having to cope with arthritis as a young mother spurred my interest in caring for others. So I have decided to re-train in healthcare. Having completed access courses to ease me into the British academic system, I have applied to study Occupational Therapy at the University of Salford. I can honestly say that it was the best decision I have ever made.

I really enjoyed my course and the extensive clinical placements I have undertaken during this time, so I couldn't wait to start as a clinician to work in the NHS. In fact, three months prior to my completion of the degree I had already managed to secure a Band 5 OT position at the North Manchester General Hospital to start upon the successful completion of my degree. But my degree also wet my appetite to study further and I was already contemplating on embarking upon a postgraduate degree. So when I serendipitously came across a PhD studentship advertised on the Guardian by the Primary Care Sciences, Keele University to study joint pain/ osteoarthritis in older people, I knew this was an opportunity I could not miss. I did -to my surprise- get the studentship despite my lack of research qualifications and being late to the interview and started in September 2008, soon after the completion of my degree.

This was a 3-year PhD studentship, and a very steep learning curve for me! There were times I thought that I was not cut for it, that I was an imposter and that I will be found out and shown the back door at some stage. I was lucky to have such wonderful fellow graduate students and we helped each-other to stand up when one of us stumble and fall. I took it day by day, challenge by challenge, and at the end of the third year, I was able to obtain a Research Assistant job at the Centre for Health Sciences Research, University of Salford. I was yet to complete my PhD, and entered into the completion phase [writing-up phase] of my PhD whilst working full-time as a single mother. At the time, the advice I received from everyone was NOT to take a full-time job whilst finishing off my PhD, as this could jeopardise my thesis submission. Nevertheless, my studentship has ended and I had to put the food on the table! Plus, I came back to Salford to continue further Occupational Therapy research in rheumatology by working with a world-leading Occupational Therapy Researcher, Prof Alison Hammond. As an Occupational Therapy researcher this was a great opportunity for me to apply the skills and knowledge I have acquired during my PhD. Well, saying that I will not sugar coat and pretend that it was not incredibly hard work, that I did not work through evenings and weekends to ensure my thesis was submitted, that I was not struggling with arthritis and related symptoms of chronic pain and fatigue that made it even harder to keep going under stress. Nor that I did not feel like the worst mother in the world when my children turned up at the school wearing a uniform on a day they should be dressed as a book character; because I have forgotten to read the school newsletter. It was hard but rewarding. So was my determination to make arthritis my job. 

Being a researcher did not get in the way of my clinical practice by the way. Shortly after the completion of my PhD, I started running a rheumatology clinic one-day/ week at the Mid Cheshire Hospitals NHS Foundation Trust which enabled me to ground my research on current clinical practices, and involve patients with arthritis and clinicians to contribute to the design, development and implementation of research projects we undertake at Salford. I strongly believe that this helps to bridge the gap between the creation of evidence-base practice in rheumatology and clinical utilisation of the new knowledge acquired through research. I now have a multi-faceted job in which I have various responsibilities as a Senior Research Fellow, Director of Postgraduate Research Studies and as an Advanced Clinical Specialist Occupational Therapist in Rheumatology. I love and cherish each role I have been given the opportunity to deliver, and take forward these expertise by participating in wider rheumatology communities such as the European League Against Rheumatism (EULAR) and the British Society of Rheumatology (BSR) scientific committees to represent health professionals in rheumatology and people living with arthritis, to influence training, policy and guidelines.

I made arthritis my job, and have written about my journey with arthritis to inspire the reader to pursue their goals, whatever this may be, despite the seaming limitations, challenges and road blocks. I think it will be apt to finish this longer than it was originally intended blog, with a quote from beloved Rumi, a thirteen-century poet, theologian, scholar and Sufi mystic:

"Everyone has been made for some particular work, and the desire for that work has been put in every heart"