The Food Medic - S8 E7: Can you eat your way to good skin?

Episode Date: August 11, 2022

On this episode Dr Hazel is joined by Dr Thivi Maruthappu - a Consultant Dermatologist in London and has pioneered the field of Nutritional Dermatology. Her research is based at King’s College, London where she works closely with Nutritionists and Dieticians to understand the relationship between nutrition and the skin. They discuss:*Nutritional dermatology as an emerging area of research*Can you really eat your way to glowing skin? *The role nutrition has in managing certain skin conditions.*The role nutrition plays in hair health*skin supplements - splurge or skip? *Skin health quick fire true or false If you loved this episode make sure to give it a review, rating (hopefully 5 stars) and share it with your friends and family. Thank you to our season sponsor WHOOP. Right now, you can get your first month free when you checkout through join.whoop.com/thefoodmedic@thefoodmedic/www.thefoodmedic.co.uk Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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Whatever groceries your summer calls for, Instacart has you covered. Download the Instacart app and enjoy $0 delivery fees on your first three orders. Service fees, exclusions, and terms apply. Instacart. Groceries that over-deliver. Hello and welcome back to another episode of the Food Medic Podcast. I'm your host, Dr. Hazel. Today I'm joined by Dr. Tivi Marathapu, who is a consultant dermatologist in London

and has pioneered the field of nutritional dermatology. Her research is based at King's College London, where she works closely with nutritionists and dietitians to understand the relationship between nutrition and the skin. So in this episode we chat all about the skin and diet and the role that nutrition plays in the management of certain skin conditions like acne and psoriasis. We also cover some old wives tales when it comes to skin like putting toothpaste on spots so make sure to keep listening to find out more. Today's podcast is brought to you by our season sponsor Whoop.

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name's Vivi, I'm a consultant dermatologist based here in London. My specialist area of interest is nutrition and the skin or nutritional dermatology. So I spend my time seeing patients but also conducting research specifically trying to answer the question, does food affect our skin? Amazing. We're going to get into that in greater detail, but let's just cover off some of the other things, some of the other factors in our life that influence the appearance and also the condition of our skin. So our skin is affected by so many things, importantly genetics. So genetic traits will indicate whether we're prone to skin conditions like acne or eczema, psoriasis, things like that.

We do have a lot more understanding of the role that our genes play in driving these conditions. But there are also environmental factors as well. So that could be pollution, it could be nutrition, stress, sleep quality, alcohol. And we call these, the culmination of all of these the skin exposome so these are all the things that your skin is exposed to during the course of your life that influence the function of your skin amazing and i mean nutrition is the field that you work in is the field of nutritional dermatology something that's quite new or novel it It's not something that I've come across in my medical school training. Absolutely. So it's completely new. And the reason I became interested in it is because of my patients. They would ask me, well, you know, I have really severe psoriasis

and I've read online that I should try this diet or that I should cut out gluten and my skin might improve. Is that going to help me? And at at this point I was the head of quite a large unit looking after people with very severe eczema very severe psoriasis and I could tell them about any treatment that was available that we could prescribe anything I could tell them all the side effects but when they asked me something so simple as what should I eat I couldn't give them a good answer and that's really as a doctor really disappointing when you can't answer a patient's question and they're sitting right in front of you. That responsibility lies with you to go away and look up.

Well, what can I tell them? And I turned to the literature and I read more and more about it and I realized that there was this huge gap and that all of us in dermatology were giving people different advice. We didn't really know what to say. And I thought well we really need some sort of guidance on this we need some research we need to be able to answer these questions that really matter to patients and that's when I started to become more involved

in nutrition research and also train in a nutrition science as well I did a certificate nutrition science because I just wanted to be able to answer that question. And that is still what drives all the work that I do now. Yeah. And do you think, I mean, because it's such a new area of research, there must be still huge gaps in the literature in terms of what we know, what we don't know. Absolutely. The gaps are enormous. And one of the biggest gaps is that we in skin have often been working in this area on our own. And we have maybe not always realized that we have this amazing collaboration that we could do with nutritionists and dietician. And that just enriches everything I do.

So I'm really fortunate. I reached out to King's and I said, look, would you like to partner on some research? And they really embraced it. And our research group comprises two dermatologists and two nutritionists and a dietician, all of whom specialize in research. And the group has just grown and grown and grown. We have medical students now, we have junior doctors with us, and it has really just grown organically. But working with them, I have learned so much from working with dietitians, how to carry out good nutrition research, how to carry out trials, how to get answers that mean something. And that has just been so eye opening. So and I

think they've learned a lot as well, because they've never worked in skin before. So hopefully I bring the skin expertise to our lab meetings and our group meetings and I think working together is really where we're going to go forwards so not just in research but also when we look after patients with all manner of different skin conditions as well. Yeah absolutely because it's not unusual to have dieticians attached to a medical clinic in the hospital in lots of other fields. But when it comes to dermatology, I guess that's something that's not being looked at until now, which is really great to hear. I'm really great to hear that it's a very big, growing multidisciplinary team with like students getting involved and other doctors. Just fascinating. And I think what you mentioned in

the beginning and that lots of your patients are coming to you and asking, you know, how does food affect my skin? How does it affect my condition? I've read this online. There is so much misinformation when it comes to skin online. And there's so much for us to go through today. But let's just kind of start with, I guess it's a very big question, but can you really eat your way to glowing skin like we read online? So when we think about how food and skin affect one another, how does what you eat affect your skin? So it can be in a couple of different ways. So we need a basic complement of nutrients for normal healthy skin function. And we also know that components of food or food groups

can aggravate certain skin conditions as well. So we really can bucket it into two different categories. So it's the maintenance of healthy skin and it's the influence on different skin conditions. But can we boost our skin with certain diet and certain supplements? At the moment, I would say we don't really have evidence that you can achieve this amazing glowing skin from just altering your diet. But it is an important foundation for healthy skin. We do need to provide our skin with the nutrients it requires, whether that's protein, whether that's

carbohydrates, or whether we're talking about micronutrients like iron and vitamin D. Your skin needs all of those things to function well. And that's why, as we learn in medical school, and as you may learn in nutrition courses or dietitian courses, the skin and hair and the nails often are the first place you'll see signs of nutrient deficiencies. So the commonest one I see is hair loss in women, and it's often caused by iron deficiency. So that is probably one of the commonest nutrient deficiencies. So the commonest one I see is hair loss in women, and it's often caused by iron deficiency. So that is probably one of the commonest nutrient deficiencies I see.

So it may not boost skin health, but it's there for normal healthy function of the skin. Yeah, absolutely. And what are some of the key nutrients that play a role in skin health? And I guess like you mentioned, it often goes hand in hand with hair health as well and nail health. Yes exactly so these are cells which turn over quickly hair cells in particular are rapidly dividing they need nutrients so things that can affect hair health in particular restricting your calories and restricting your diet can profoundly influence the quality of your hair and low calorie diets in particular can increase hair shedding because it places stress on the scalp and the hair growth. And in addition, iron, as I mentioned, is really important for hair health.

In terms of macronutrients, hair is made of protein. So we need to have protein in our diet as well. B vitamins, for example, B12 is also important for healthy hair and actually B vitamin deficiency can be linked to premature graying of your hair as well. Zinc and selenium as well are important for hair health and we often hear about biotin and hair health and biotin supplements although we need biotin for normal hair growth there are so few of us who are biotin deficient and they've conducted lots of studies in people who have hair loss and they haven't really found that biotin deficiency is a common feature. And this is something where we need a certain amount

of biotin in our diet for normal function. But the question is, do we need extra to help our hair grow more? And at the moment, the evidence doesn't really point to that. Although if you look at any hair supplement, you're going to find biotin in it. It doesn't seem to point to boosting hair growth. Yeah, it's often the case with when it comes to deficiency in supplements and things. And it's easy to believe that if something's good for you, then more is better. But it doesn't always work that way especially when it comes to supplementation in terms of nutrients for skin health then would your top ones be ensuring you're getting enough calories protein omega-3 and like you mentioned the antioxidants zinc and selenium what are some other key nutrients that you think are particularly important for someone to be

thinking about for their skin absolutely so vitamin d is a really important one. And there is an enormous amount of research into vitamin D and skin health. And it's not only made in the skin, but it's important for the function of the skin, for the skin barrier, particularly, it's important in maintaining that. And there are many skin conditions where the skin barrier doesn't work as well. And the most important one of those is eczema. So particularly with my patients with eczema, I'm very mindful of checking their vitamin D levels. And in psoriasis, we actually treat it with vitamin D creams, as you remember.

But there is also a role of supplementing if levels are low as well. And that seems to be helpful for psoriasis. And remember, this is not having higher than normal vitamin d levels it's treating nutrient deficiencies yeah that's a really important point and so a lot of your research is in psoriasis and and the kind of role of nutrition there what is really important when it comes to managing psoriasis what are the key nutrients that may help manage the condition or may hinder the condition as well? So as we mentioned in the beginning, many skin conditions are multifactorial and psoriasis is a perfect example of this. It's influenced by so many factors.

It's very strongly genetic, so there's often a family history, but it's also affected by environmental factors such as stress. But also things that we're doing, lifestyle things like alcohol like alcohol smoking they can all make psoriasis worse and from the nutrition point of view much of the research that has been carried out in psoriasis has looked at the effect of weight on psoriasis and what having a higher body mass index in research terms has on psoriatic disease and psoriasis is linked with many other conditions and we have a much greater understanding of that these include diabetes and heart disease and really i don't want people to be frightened of that it is more in severe psoriasis so people have extensive skin involvement but it's important that when we're looking after people with psoriasis we always address

all of these other factors and treat the patient as a whole so if their blood pressure is high we'll be talking about salt if their cholesterol is high we'll be talking about what are the best dietary ways to lower this and medication if necessary but the best diet for psoriasis so that's the topic of our research that we're looking at at the moment. So we're conducting a trial called the Apple Study, which is part of the diet and psoriasis project. And we're asking people with psoriasis, how does diet affect your skin? And then the next step building from that, we're going to ask people with psoriasis to try different diets as part of a clinical trial and see what the impact is on their skin. And the reason we've decided to do that is because this is the question that people are asking, which diet is better? And we don't really have a way of answering that yet.

And so much of research to date has focused on the effect of weight and psoriasis. But we're not looking at weight, we're looking at the quality of diet and I think that's really important because there isn't enough research in that area as well. Yeah I think that is important. Gluten often comes up when we're talking about psoriasis can you talk a little bit about the link between that? So gluten is a really interesting one because a gluten-free diet is touted as the answer for everything as as I'm sure you know, and you probably get asked about all the time. But there is some evidence to support a gluten-free diet for psoriasis. And it's really interesting. So if you have celiac disease, which is autoimmune condition where you're reacting to a protein within wheat, gluten specifically, and you are eating wheat, and you also have psoriasis, your psoriasis can improve just by

cutting out gluten. And that is if you have celiac disease as well. If you have the positive blood tests for celiac disease, but you don't have full blown celiac disease and you have psoriasis, again, if you cut out wheat, your psoriasis may well improve as well. But if you are negative for all of those tests for celiac disease, cutting out gluten doesn't seem to have any added advantage in managing psoriasis. So there is a role for it, but it's very specific. Yeah, I think that was really important to cover off because it's something that comes up a lot. And gluten-free diets aren't necessarily always better for us, are they?

No, absolutely. We talked about that in a recent podcast they're a lot more expensive they're low in fiber lower in protein higher in salt so yeah save your money and definitely get tested if it's something that you think applies to you like you said but it's good to know that it's not something that everyone should be absolutely jumping towards totally and in the clinic I ask questions about gut symptoms to see if it's a test that is relevant for that patient so. Yeah absolutely. Acne is another thing that I'd love to speak to you about something that I've suffered from as an adolescent and then again as an adult and you know there's so many articles online about

what you should and shouldn't eat and I think we've all been exposed to messages from even friends like if you eat sugar you're going to get spots x y and z what role does nutrition have to play in acne so I'm so glad you asked that because that's the question I get asked more than any other even when I'm speaking at dermatology meetings at conferences and I may be giving a talk about psoriasis, someone will always ask me about acne at the end. It is the number one question all the time. And it's because there's so much misinformation out there. And it's actually quite a difficult question to answer because there isn't a really straight answer.

So I'll talk from the experience that I have from the clinic. And I've been looking after patients with acne for about 14 years. I've worked in a very specialist unit for acne as well. And when I first started in dermatology, we were all told it's just got nothing to do with food. Tell patients to eat whatever they want. But patients would tell me, look, I know when I eat certain foods, I will get an acne flare up. But it doesn't mean my acne clears when I remove that food. But I definitely know that there's a link. And I kept hearing all of these stories from people who lived with this condition. And they knew, you know, you know when something affects your skin. You can really grasp if you're eating something and then, you know, the next day you have a breakout.

You really need to listen to people when they're telling you this over and over again. I started to delve a bit deeper into the research. And what does the research tell us? Well, the studies are generally quite poor. They're mainly observational studies. So they're asking people, do you notice a link between acne and what you eat? And an observation doesn't always mean that the relationship is 100% causative. So we just have to take that with a pinch of salt. But larger studies do point to a couple of culprits. One of the culprits is low fat dairy products. And one of the other

culprit that comes up from some studies is a high glycemic index diet or a diet that has high in refined sugar. And that doesn't mean that if you have acne, you cut those two foods out and your skin clears. Because I have plenty of patients who come and see me, they are at the end of their tether and they're booking their appointment because they come and the first thing they say is, I've tried everything, I've cut out everything, I'm only eating this, this, this and this, my acne is still there. So this is where genetics plays a role, hormones plays a role. So acne is really caused by your genes and your hormones. And as women, we know that. We know that hormonal fluctuations can cause acne to break out and flare up. But food for some people can be a trigger.

And there'll be people whose acne is highly sensitive to diet. There are people who really notice the difference with what they eat.. There are people who really notice the difference with what they eat. And there are people on the other end of the spectrum who can try removing certain foods from the diet but see no improvement. And the problem is that we don't have a good way of working out where you are on that spectrum. And the people who see that their skin clears with certain diets can be really vocal about that on skin clears with certain diets can be really vocal about that on social media or they can be really vocal about that in your life they can say look i cut out dairy my skin is great you need to do the same and those people are talking to people

who basically have a condition that's responding very differently and it's that disconnect i think that's out there and i would say even amongst colleagues, only about half of dermatologists surveyed in a study of 50 dermatologists felt that diet played a role in acne. Whereas when they did a similar survey in people sitting in the waiting area, waiting to be seen by a dermatologist, these people with acne, about 90% of them felt that food affected their skin. So there's a big disconnect between what dermatologists think and what patients think. And it's probably because we as dermatologists, we don't see the people who clear when they cut out milk. We don't see them. Why would they come

and see us? They carry on with their milk-free diet and they're fine. But we see the people who may have tried things and their skin is still suffering. Yeah. And like you mentioned, we just don't have enough good quality evidence as well to start making these huge dietary changes, which can be problematic themselves. That's so interesting. Wendy's most important deal of the day has a fresh lineup. Pick any two breakfast items for $4.

New four-piece French toast sticks, bacon or sausage wrap, biscuit or English muffin sandwiches, small hot coffee, and more. Limited time only at participating Wendy's Taxes Extra. What other skin conditions would you see in clinic typically that nutrition plays quite an important role? So I would say eczema is one that comes up a lot. So I deal with adults with eczema. Children with eczema are actually really well looked after because there are lots of pediatric allergy specialists and pediatric allergy dieticians, but we don't have the same in adults with eczema. People with eczema often wonder,

is food making my eczema worse? And that's more of a straightforward answer if you have a true allergy. So if you've got a shellfish allergy and your eczema gets worse and you get urticaria or hives when you've eaten some sort of shellfish, that is a much easier connection to make. And you might even have an EpiPen or you might need to take an antihistamine. So that's more of a straightforward connection. The problem is that there is another type of reaction, which is a delayed reaction. And that type of reaction is really difficult to work out because it can take even three days to elicit a flare of your eczema. And in the meantime, you've eaten so many different foods, you have no idea what the original

trigger was um the other problem with that type of delayed reaction is that there isn't a good test for it we do not have good tests for that and that's where i see patients become very vulnerable to marketing for food intolerance testing and as you know and i know those tests are not validated um and i have seen people who've tried food intolerance tests, the hair tests or the prick tests. And they come and they print out the report and they say, well, I've had this test, I need to cut out all these foods. And really, you don't need to cut out all of those foods. Actually, if you cut out all of those foods, you will most likely end up

with some sort of nutritional deficiency. And for sure, I have seen people who've done that and come to see me and I'm really working on reintroducing foods with them with an allergy dietician. And you can really also end up worsening food allergies. If you cut out food from your diet that your body has become tolerant to, sometimes when you re-expose it, you can actually make that intolerance worse. So it's important that you don't cut out foods willy-nilly. Yeah. And I think also the psychological component, if you believe that something is causing you harm and you have a, you know, you've done this test that you've ordered online and it says the same thing, reintroducing that food can also come with loads of problems. And it's almost like this nocebo effect where people think, I can't introduce this this in so if you feel like you're struggling

definitely get the support of a nutritionist or a dietitian who can help you reintroduce those foods because I've just seen it so many times um you're so right it's it's really scary because um yeah I have people who've tried very strict exclusion diets on their own. They've read something online. And when they come and see me, they're eating so little. They're eating brown rice, chickpeas. Their skin is still terrible. And their eczema is still keeping them up at night, really itchy. But they cannot introduce the dairy back.

And so I work to treat the eczema. And then I refer them to a specialist dietitian who can support them, bringing back each food one by one. It doesn't have to be chuck everything back into your diet. It's a slow process, but we get there. Yeah, I guess the trap that people tend to fall into as well is the supplement trap. And if you are struggling with your skin

and you don't feel like anything that you're doing is helping and maybe you've tried cutting out certain foods and then you see this supplement that an influencer is using and it's improved their acne or it's given them the most beautiful glowing skin, you go and you buy that supplement. Where are we up to in terms of skin and supplements and are there any that you would back in terms of the evidence?

So I use supplements when I'm treating a deficiency. So if someone is low in iron or vitamin D, or if that patient is, if they have a specific diet. So I have vegan patients and it's really important that we make sure they're getting enough B12 and they're getting their omegas. So supplements play a very specific role, but I don't give supplements as an extra, as a topup to treat conditions. How about collagen? Oh that's another one I get asked about all the time. Collagen is really interesting so I'm quite open-minded about collagen and I'd love to see more good quality research about it. So they've looked at the evidence they've had a meta-analysis on all the

studies and a meta-analysis looks at lots of different studies together and it compares them to see what is the overall overarching theme. The problem with a lot of the research studies into collagen is that they're funded by manufacturers so you always have to take that with a pinch of salt. Overall though that meta-analysis did feel that there was a benefit to the skin for taking collagen supplements namely skin thickness and moisture retention, which I think is really interesting. And I read quite a lot of collagen studies. And collagen is this huge protein in the skin. And it needs other things to form, particularly iron and vitamin C are required for healthy collagen. And a lot of the supplements

are just collagen fragments. So collagen broken up into little peptides, so either pairs or larger groups of proteins. And it's really interesting because we always think that protein should just be broken down in the gut and they won't be absorbed as pairs or smaller particles. But some of the studies actually show that consumed collagen is in the bloodstream which is interesting and we're using collagen peptides in skincare all the time so collagen peptides if you look in lots of beauty brands you'll see that they're used and the studies that they use to confirm that they work when applied to the skin are that they use those little fragments of collagen and they apply them to cells called

fibroblasts and this is all in a culture it's not in a person and what they do in fibroblasts is they encourage them to produce more collagen so the mechanism for how collagen supplements is work is interesting but we just do not have concrete evidence to show that taking them by this mechanism improves collagen in the skin. But if people want to take it, I've had patients say, look, I take collagen, I like it, I'm not going to stop them. And if you want to try it, try it for three months and see if you notice a difference. And if you don't, then discontinue. But you have to be careful not to change lots of different things in your skincare routine at the time. We should be getting collagen, the components of collagen from our diet,

really the proteins in our diet should be adequate to provide us with all the amino acids that we need to make collagen. But, you know, I'm open-minded to it. Yeah, yeah, I think TBC, we'll see what the research shows. But I think I agree with you. The most recent evidence seems to be a bit more promising

when we pool everything we have together. But I do think that it's not a panacea for improving kind of your skin health. And I would focus on all the other things, the low hanging fruit first before shelling out your money, because they can be quite expensive. Yes, definitely. Especially if you, you know, the liquid ones are extortionate. And when we talk about diet and skin, what really interests me is that people are willing to eat healthier for their skin. But as we both know, they're eating healthier for their skin, but this is their long term health that they're helping as well. And that to me is massively rewarding as

well. Yeah, I completely agree. So I have some quick fire myth busting for you based on things that often come up online. So this is kind of a true or false, but you can go into more detail. I'm sure you will. We kind of covered off this one already, but sugar causes acne. So no, sugar doesn't cause acne. So we know that genetics and hormones are the most important factors that drive acne. But for some people people with acne sugar can be a trigger awesome the next one is makeup with spf is enough to protect your skin from the sun so that that one's a bit more tricky so i mean i always recommend using a separate spf because you're going to get better um coverage that way so you should be using a teaspoon for your whole face. And most people don't use a teaspoon of foundation with the built in SPF. So most of the time you're not using enough

to give the level of protection on the bottle. And if you really want to guarantee that you're getting adequate protection, I use a separate SPF always. And that is the number one thing you can do to protect your skin from the sun and uv amazing um putting toothpaste on spots gets rid of them it's just really irritating and there are so many better things around you know what i mean there are so many ingredients that really work like salicylic acid or benzoyl peroxide i would always reach for those before i went to the toothpaste that touches my toothbrush you know what I mean I used up a toothpaste on my skin when I was in school I was like this is the only thing

pseudocrame everywhere toothpaste everywhere um people with oily skin don't need to moisturize so um whatever your skin type you should be moisturizing because even if you have oily skin it can be dehydrated and if you have oily skin, it can be dehydrated. And if you have oily skin prone to breakouts, you might be using products that are a bit more drying like salicylic acid or benzoyl peroxide. And in those cases, it's important to protect your skin barrier. Yeah, absolutely.

For someone with quite oily skin, what type of moisturizer would you recommend then? I like the gel ones. So the lightweight gel formulations. There are some oils that are suitable for oily skin, but I tend to shy away from them because they can increase the risk of breakout. But I love lightweight gel formulations for oily prone skin and always look for non comedogenic, so not pore blocking formulas. Okay, perfect. Silk pillowcases prevent acne and wrinkles forming they may feel really nice to

sleep on but they're not gonna prevent acne and it's a big myth that not changing your pillowcase and things like that causes acne it's just nothing to do with your hygiene um but in terms of wrinkle formation although look it's never been studied but there's less friction on a silk pillowcase so that might be why some people prefer to sleep on them my mum got me a silk pillowcase. So that might be why some people prefer to sleep on them. My mum got me a silk pillowcase when I turned 30. Yes. For that reason. And I've not used it. I'm really sorry, mum.

And she's also telling me, always sleep on your back because you'll get wrinkles if you sleep on your side. Your mum knows what she's talking about. She looks amazing. So I would listen to her. The next one actually ties in quite nicely. Beauty sleep is real. Good quality sleep

is important for your skin health. And it can be really frustrating because many skin conditions can lead to a poor night's sleep. So if you have bad eczema, you are up at night itching. It's so frustrating. You cannot get that sleep that your body desperately needs. And sleep is a time where we regenerate. So it's when skin cell turnover is at its highest so we do need to protect our sleep but if you are sleep deprived your cortisol levels go up and that's our stress hormone and we know that stress worsens many skin conditions it can lead to breakouts it can worsen your psoriasis it can make your itching worse as well so good quality sleep is important for so many aspects

of health, including skin health. Amazing. We love sleep on this podcast. And so to finish, we have three questions which we ask every guest. The first one is, what is the number one takeaway that you want everyone listening to take from this podcast episode? So when it comes to your skin health and nutrition, there is no one size fits all approach just because something has worked for somebody online that doesn't necessarily mean that it's going to work for you i always give very individual advice it's individual even within the same skin condition so just because you've tried something that someone else has tried don't beat yourself off about it don't blame yourself because your skin condition hasn't cleared there are so many people like you out there amazing and what is the most important

lesson you've learned over your career oh listen to patients always listening to my patients i have learned more from my patients than i will ever learn from any book or journal i would not be doing what i'm doing if they hadn't told me the problems that were out there. I wouldn't have amassed so much useful information if they hadn't taught me about how nutrition affects their skin. And really, that is still the drive behind every research question that we ask. Well, that was a question I got asked in clinic, how are we going to answer it? So it's always anybody who is in the healthcare profession, it's listening to your patients, listening to your clients. Yeah, it's so important. It's so easy to kind of keep referring back to textbook and guidelines. But like they say, medicine's an art, not a science. So, you know,

you have to use your judgment and what the feedback that you're getting from your patients as well. Yes, absolutely. And the last one is what's your motto in life? So I suppose it's not a motto it's more of a quote from maya angeli and i actually saw it when we were walking in here on the wall and i thought oh that's my quote and i was really excited so it's um people may forget what you said people may forget what you did but they will never forget how you made them feel and i know that from both sides and it's something I've learned as I've progressed throughout my career. So I really think much more about how what I'm saying

and how that has an impact on how it's making somebody feel. And I want people to feel good. You know, I want people when they come and see me, I want them to feel like they've been listened to. I want them to feel that there's hope and leave feeling good and it's that feeling that's really important That's lovely And if people do want to feel good and follow you and find out more of the work that you do where can they find you? So you can follow me on social media

I post intermittently I need to get better at it you'll have to give me some tips It's at Dr. Thivy Maru Amazing Thank you so much for coming in today and for sharing your knowledge this was a really interesting podcast thanks hazel thanks for having me on thank you so much for tuning in today if you loved it you know what to do leave us a review

a rating hopefully five stars and share it with someone you know will love it too that's all from me see you again next time