Episode 91: Mastering Metabolism with Ronesh Sinha, MD

00:00    this is the one thing podcast and I'm your host Dr Adam Rinde the one thing podcast brings together leaders in functional and naturopathic medicine to discuss actionable information that may unlock puzzles in the areas of gut health brain health metabolism and Longevity please note these episodes do not replace the opinion of your doctor they are not intended to diagnose or treat any condition please discuss this information with your provider and discuss your own unique personal health history before adapting this information

00:36    please subscribe to our episodes so that you can stay on top of the most current information in these areas of Medicine greetings everyone this is Dr Adam Rinde welcome to this episode of the one thing podcast I'm delighted to share with you a conversation that I had with Dr Ron sinna who is an internal medicine specialist out of the Silicon Valley area in California you'll quickly see that Dr SInha is a expert in metabolic health and our conversation did not spare many aspects of metabolic Health we go into insulin

01:15    resistance dyslipidemias obesity fat gain things to do about these issues we speak deeply about South Asian Health which has a number of metabolic risk factors that we discuss in detail and generally look at this concept of metabolism and mitochondrial function Dr Sinha is very practical and he has very practical steps he's very balanced in his views he doesn't promote any restrictive ways or restrictive Lifestyles he's just really looking at how to optimize your body so that it can counter the effects of mitochondrial

02:02    aging and are generally more progressively sedentary lifestyle I think you'll really under really get a good understanding of metabolism just by listening to this episode and it should inspire you to learn more about these topics from some of our other episodes and then to get on board with his podcast which I mentioned is called the meta health podcast and Dr Sin has also written a book he has a number of courses he really knows his stuff and I just had a great time preparing for this this interview and then sitting down and

02:40    actually having the interview so without further Ado I welcome you to the next episode of the one thing podcast Dr Sinha welcome to the one thing podcast it's so great to be here with you today pleasure pleasure's all mine looking forward to our conversation yeah so I mentioned Offline that how much I've been enjoying listening to your podcast and I'll love for you to share more about that later and the courses that you're doing and all your your wonderful work in this space I'd love to first start off our

03:18    conversation just hearing a little bit about who are some of the key mentors that have influenced your clinical style and educational Style yes absolutely you know so when I started with my internal medicine practice you know I was traditionally trained in Internal Medicine and started my primary care practice predominantly in the Bay Area and you know when I applied sort of the general principles that I learned in medical training although it was useful to some degree I found in the area of Lifestyle management I had a big gaping hole and

03:51    just providing sort of the traditional you know teachings very minimal teachings on things like nutrition and Metabolism just wasn't meeting the burden of obesity instant resistance that I was seeing in the clinic and especially on a very young population so I would say my first mentor and I'm kind of Lucky to say this was Dr Jerry Riven who was at Stanford University and if you don't know Jerry Riven uh the late great jury Reven he actually founded insulin resistance in metabolic syndrome so he was the gentleman the

04:20    coined metabolic syndrome and when I was writing my book on sort of insulin resistance in South Asian how I have the honor and privilege of meeting with him a couple times and exchanging emails back and forth so he really took my Approach my traditional approach to heart disease prevention which really for traditional doctors is a very LDL Centric approach and this was over 10 years ago and you really helped me refocus on the burden of insulin resistance which we'll talk about so I'd say he was like the first Mentor for me

04:47    and I was really honored to have that connection with him now kind of pivoting to outside the traditional research and Medicine world my next Mentor was actually a gentleman that you probably know his name mark Sisson who is kind of the you know person behind the Primal movements back during the Rob walk in the Primal days and so when I was kind of um pitching my book to several Publishers to write I fortuitously came across Mark Sisson through a workshop through one of his colleagues and I never imagined that he would be the one

05:15    to publish a book of line which is really predominantly geared towards a vegetarian Indian population but he had such an expansive open-minded approach to Lifestyle and Metabolism that it was really the perfect marriage between my work with Jerry Riven and then really understanding what do athletes go through and what was his own journey and his huge audience that he has all throughout the world what is a messaging that he's using you know for Mark's Daily Apple  his popular blog and that's where I really became engaged around dipping

05:44    deep into science traditional medical research but also seeing what's happening in the world of athletes and other folks that are high performance folks so I'd say those two interactions were really influential on me and then there's been a host of other interactions that have taken place too but you know when I look back I think of those as being sort of my initial mentors in this space that's such a great combination you know having sort of the the solid educational uh background from coming

06:11    from Stanford and then having someone like Mark Sisson who's actually really taken this information and mobilized it to people and help people use it that's that's a great combination I've been following his work since uh I think 2006 or so so is a great one yeah so and one of the ways that we were connected is I was really drawn to your work with Southeast Asian metabolic health because living in the Seattle area and especially in Bellevue area where I live this is a major issue that we talk about

06:53    quite a bit with our patient population so I can't wait to hear and learn more about that later today yeah so the bigger question I'd love to start with is why why should we care about our metabolism I mean you know on one hand my grandfather who's from Europe he grew a big belly and you know lived life eat drink and be merry and just like lived life he had did definitely had some stressful stress risk factors and had a very challenging life but he lived well into his 90s and then other people I know who

07:36    really stress a lot about their their waistline and you know spend a lot of times worrying about being overweight will have an earlier departure and that's just a basic example but why should we care about our metabolism yeah I I like the way you frame this because I do think in our current Society you know I'm just going to delve into this it's a little bit off track but I think we're overly obsessed with body fat and when I think of my own Indian ancestors and some of them that look to be in their 80s and 90s they

08:11    were not sporting six-packs and when you look at Blue zones or okinawans and if they all take their shirts off without shirtless picture people would be not be looking like Mark Sisson in their 60s right well I do think that there is a big problem with us basically identifying our body fat as being the clear marker of metabolic Fitness and disease when there's so much more to this metabolism than just that and that's why even individuals you know that I see in my clinic that might have come across a podcast or they looked at

08:39    a table of what is an optimal body mass in desks or a waist circumference or they got dead to skin done often they feel very terminal based on what they're seeing on those body metrics even though when we dig deeper and we look at the metabolic numbers things like triglycerides in blood sugars and other simple numbers those numbers are right on the mark so often I am really trying to reframe things for my patients and my clients to say let's focus on the big picture numbers now coming back to the word metabolism metabolism is a very

09:08    complex word and and really at a very high level it is how is our body taking those incoming nutrients and converting it into energy so if we think of our metabolism as being an engine are we putting the right nutrients inside that engine the right Fuel and are we getting adequate output to basically serve our daily purpose of physical activity mental energy all of those things now you know in a very closed system in a very sort of two-dimensional image we would just be thinking about nutrients and exercise and think that that's all

09:38    there is to metabolism but now what we've really understood over the last few decades thanks to a lot of wearables and different Technologies is things like stress emotions connection loneliness these factors which I probably would have pooped let's say 15 years ago now we're seeing these have direct direct metabolic consequences and later on we can talk about this but when you put on a continuous glucose monitor and you see what happens to your glucose level after Poor night's sleep after an

10:05    argument with your partner you will be convinced that some of these interactions are as devastating as you eating a bowl of chocolate ice cream or whatever your favorite sweet is so I think metabolism again very simplistically nutrients into energy but it's a much more global system and now I even talk about how emotions are actually nutrients right there is a emotional index just like the glycemic index in terms of what our daily experiences like and what impact does that have on metabolism so that's kind

10:31    of my broader approach that I've evolved into after using wearables and other things to see what are those other non-nutrition non-exercise factors that can really influence that engine yeah and there's sort of this overlap with metabolism being kind of a hub of like you're you're saying involved with breaking down and burning nutrients but also involved with inflammation in our body also involved with possibly cancer processes can you talk about sort of like the the big landscape of how metabolism interfaces with some

11:08    of the the topics even things like cognitive decline yeah so um if we're going to look at one of the Myriad sort of Branch points or Pathways within metabolism let's think of like the mainstream of what you'd learn in Biochemistry class or just basic you know nutrition metabolism and basically when we are consuming let's focus on macronutrients when we're consuming things like carbohydrates fats and proteins they're going to be coming into our blood system and they're going to be entering our cells and I want to

11:38    focus for a moment specifically on carbohydrates and fats because those are the predominant energy producing macronutrients when they enter our cells basically they migrate into a structure so think of a structure inside a structures we've got our cells and inside that I'm sure you've talked about this in past episodes we've got the mitochondria and what happens is when you see these disparate nutrients you know if you look at the structure of carbohydrates and fats they're very different looking but they're really

12:05    come down to being hydrocarbon units all right hydrogens bonded to carbons and what happens is a process of digestion and metabolism them we take all of these disparate macronutrients and we turn them into two carbon units basically and we call these acetyl groups those basically are inside the mitochondria and the mitochondria then goes through a series of steps to convert that two carbon unit into ATP energy and one particular process that I want you to be aware of inside that mitochondria is the Krebs cycle and I'm not going to bore

12:38    people with the different steps of the correct cycle but I tell people think of that as being a turbine engine or a merry-go-round that spins around and around and these two acetyl or two carbon acetyl units they go inside that Merry-Go-Round they spin around and they produce ATP energy as a result of that so in an ideal system we're going to have just enough nutrients going inside that mitochondrial Merry-Go-Round to produce the energy that our body needs on a daily basis but what happens with over nutrition is when we're consuming

13:09    too much food and we're not actually using that energy in a physical exercise sort of way a picture that Merry-Go-Round becoming overcrowded there are so many two carbon units trying to hop on that Merry-Go-Round that the Merry-Go-Round for us to slow down it cannot convert all that incoming nutrients into energy and then what the body does to respond to this is it diverts those excess nutrients in different directions it might convert those excess nutrients like carbohydrates or excess fats into triglycerides and lipids and that are

13:39    exported to other areas it actually inhibits the insulin signaling mechanism so instead of us being able to really metabolize nutrients efficiently we're storing them and then really what happens is in any overabundant situation in our metabolic Network when you cannot actually convert nutrients to energy you start to produce these byproducts these oxygen radicals which are potent oxidants you increase inflammation in the body and I'm sure you've used the word inflammation numerous times but that is really like rusting that engine

14:11    it really brings that Merry-Go-Round to a screeching halt and that can lead to all the downstream consequences so those toxic radicals can produce insulin resistance which is a root cause for diabetes and heart disease and also neurocognitive issues neurodegenerative diseases like Alzheimer's you know clearly when you have cells that are becoming dysmorphic or misshapen or proteins are becoming misshapen because again you can't handle that nutrient capacity then all of a sudden you're increasing the

14:40    you know the risk of other chronic health conditions like cancer as well and you're accelerating the aging process so there's a lot of different Pathways for those different chronic diseases but a lot of it really comes down to that fundamental law of nutrient over congestion exceeding that mitochondrial engine capacity and then leading to all of these other overflow Pathways that can really drive a chronic disease and you know I've I've got a little bit of a bias because I've done so much work within insulin resistance

15:08    so in my brain I'm always thinking of sort of glucogenic or insulinogenic type ways in which these Pathways take place so Alzheimer's disease for example multiple processes that can cause this but when our body is producing excess excessive amounts of insulin that can really have influences on the brain in terms of how we're able to clear amyloid and other protein type malformation inside the brain but but that'd be a high level on that basically yeah so starting with that your mention of over

15:37    nutrition leading to all these sequelae or aftermath events that contribute to the imbalance and the disease process and the inflammation if that ends up being insulin resistance how how would one start the steps of reverse engineering that I mean if it if it's as simple as well you know just cutting back on consumption of nutrients is there sort of this this path that needs to be repaired or corrected first before that's actually established as a preventative process yeah so so let's um dig a little bit

16:24    more deeply into insulin resistance specifically and I'm going to use sort of my again using a car sort of uh or a traffic network type analogy and then we're going to get to the root cause of what are some of these things that causes insulin dysfunction and I'm focusing for a moment on carbohydrates since that can be predominant macronutrient in excess it drives insulin resistance so my work I kind of describe that carbohydrate or glucose molecule like a car and there's three major parking lots you've got your

16:49    muscle liver and fat and really in an ideal metabolism our muscle parking lot should be clearing about 80 percent of that incoming glucose trap it basically the glucose goes to that muscle parking lot it causes an increase in insulin insulin opens the gait and that glucose gets inside that muscle so really that's an optimal metabolism is when the muscle is doing the line share of clearing glucose from the blood now what happens is when the muscle for various reasons which we'll talk about when it starts to

17:19    actually not respond to that signal what happens is we develop insulin resistance so if insulin is the parking pass the muscle attendant you know the gate guy is basically trying to you know put the pass inside but the muscle's not responding so now we have this overflow glucose traffic and that can go in various directions so let's start off the liver parking lot the liver parking lot does have fixed limited space to hold that glucose and the storage form of glucose is a glycogen so typically about 100 grams of glycogen in the liver

17:48    when the liver runs out of that space that overflow glucose goes through a pathway we call DNL or denovo lipogenesis and that's basically the conversion of glucose into fats and the problem is even long before you've developed a commonly known condition as fatty liver when you start to microscopically develop more fat droplets inside the liver those tiny fat molecules can interrupt insulin's normal action and then the liver what that basically means is your liver is going to be pouring out more glucose in your

18:19    body needs it's going to increase the process called gluconeogenesis so that's excess glucose traffic that's been directed into the liver which produces that extra fat and then expels extra glucose and also expels along with that triglycerides which is a storage form of fat inside the liver as well you've also got overflow traffic that's going toward fat cells and I kind of joke that you know your muscle has got fixed limited parking space so that parking lot has limited space your fat cells that fat

18:48    parking lot has unlimited parking space it's open 24 7 right so you can get hundreds of pounds of body fat from that diverted traffic going in that direction and that's what can lead to increased visceral abdominal fat along with subcutaneous fat as well I want you to visualize that situation because that's going to tell you what are your individual risks and manifestations for insulin resistance for example some individuals might just have elevated waist circumference so visualize that means most of the glucose traffic is

19:18    going towards that fat parking lot but maybe it's not overwhelming the liver too much yet which is why you may not yet have elevated blood sugar elevated triglycerides other individuals interestingly see that very little traffic is going towards the fat cells may be just enough to add an inch or two along the belly but most of it is going towards the liver and that's generating a lot of triglycerides and a lot of glucose if it looks like that's interrupting the insulin signal so that could be our slender relatively slender

19:46    individuals who don't have much diversion to fat but most of the damage is happening at the liver level so that's the other pathway now when you think about insulin transduction it's kind of like a circuit you know so insulin basically attaches to the cells and it sends a lot of Downstream signals to allow your body to clear glucose if you were to look at three categories of areas that interrupt that circuit the most I would basically say number one would be inflammation so excess cytokines which are the inflammatory

20:17    chemicals in the body the second is hyperinsulinemia so having excess insulin in the blood so when your muscle cells are not responding to that insulin parking pass the body responds by over producing insulin and that excess insulin will feedback inhibit insulin's normal signaling pathway and the third thing is those toxic fats that I talked about there's words for that we call them diacylglycerol or ceramides those can also short-circuit that insulin signaling pathway so to remember this for you practitioners out there people

20:50    listening I say three things it's static it's cytokinemia it's hyperinsulinemia and it's toxic dyslipidemia if you can think of those three categories those are Central factors that can really interrupt that insulin signaling mechanism so then for some people if it's just hyperinsulinemia that's the predominant Factor if you focus on lowering those excess carbohydrates and exercising doing intermittent fasting maybe you're going to wear a CGM and keep track of your glucose response even

21:18    though you can't measure insulin when you're really Contracting those glucose with spikes and controlling that the hyperinsulinemia might be controlled and that might be sufficient to reverse that instant resistance there's other individuals that don't show signs of hyperinsulinemia but it's all coming from cytokines  so it's coming from chronic inflammation which can be from a chronic infection from emotional stress an inflammatory diet so that's the other element we think of and then that

21:45    dyslipidemia again that can be a downstream product of any of those interacting the wrong way so I'm simplifying it by saying three categories but as you know these are always overlapping hyperinsulinemia drives inflammation increased inflammation drives insulin resistance and hyperinsulinemia but those are categorically the three ways I think about it and then with each patient I try to decide where is the area that we can make the most impact initially if they've got elevated blood markers for inflammation HSC reactor protein maybe

22:13    we're going to attack inflammation first or an anti-inflammatory diet and other mechanisms if it looks like they got a lot of high triglycerides or elevated blood sugar and they're clearly from a dietary intake consuming too many carbohydrates and calories we might attack from a dietary standpoint so sorry that was a long explanation but I thought I'd break it down for you in the way that I typically do yeah I love that and I love the the kind of three different channels to look at and how they can be

22:43    be activated in in it it's not just one pathway there there's multiple different ways that insulin resistance can can manifest and the parking lot analogy is amazing unfortunately one of the like you said one of those parking lots just gets bigger and bigger it's like it's like an airport sometimes yes unfortunately yeah now I think one of the the things that you talk about in your in your teaching and I I want to just plug this in here at this moment because I'm sure a lot of people who are listening to this are

23:23    thinking well you know what what do I do about this and we're going to get to that I'm sure but I really like how that you talk a lot about layering different modalities and different interventions and that is really I think a really good concept to talk about how people seem to in in this space kind of pull back on one lever like okay so you're telling me I have insulin wrist and resistance okay so I'm just gonna go pull back on every single carbohydrate or I'm going to just go get huge in the gym

24:09    you know become massive with lots of muscle mass I'm going to cut out every single food that has inflammation associated with lectins and gluten and dairy and all that stuff so how how have you evolved to see how it's not just like one lever and it's just more of kind of making it work for the individual maybe it's a little too early to go into this but I I just wanted to put this in here because I think a lot of people get really anxious about sort of these all or none approaches yeah you know I'm so glad you brought

24:48    that up because I think we are now living in an era of overly restrictive dietary practices and it's become a real problem I'd say 10 to 15 years ago this really wasn't a factor is almost everyone who walked through my door was overnourished in some way or form but now because of the onslaught of so many different camps of over-restrictive dieting often when I'm doing dietary intakes I would say at least half of my patients and again I'm here in Silicon Valley different demographic I know it's

25:15    different different parts of the country and world but I would say at least half of my patients are really undernourished in an affluent way these are people that have read a lot about science they're following a lot of podcasts and they're over fasting or they're scared as hell about any chemical in any food because they think it's going to trigger inflammation and really they don't enjoy eating anymore it's like food is a toxin to them and they try to limit that as much as possible so for me I have to

25:40    kind of hit the reset button and work on okay let's try to introduce things into your diet that we can enjoy boy and that's going to make this sustainable because these people are you know losing the wrong types of weight and their mindset around eating and exercises become really dysfunctional and you see these clients in patients as well too they're over fasting they're over exercising and they're not necessarily seeing the results that they want so the first thing with each patient if they're

26:06    coming in and I'm already looking at their lifestyle regimen and they've been doing something very restrictive whether it's a severe autoimmune diet fasting keto Etc and they're over exercising it's really identifying intuitively and based on their lab numbers what is the area that we probably need to work on the most okay since you're restrictively dieting so much nutrient congestion probably isn't a big issue I'm not worried about you being overnourished what I'm worried about is the fact that

26:32    I'm looking you right now your arms and legs are skinny you are doing a lot of endurance work but we need to build more parking space and again this comes back to the cultural aspects where when I see a lot of Asian patients or Indian patients you know they have very slow blender arms and legs and they don't have much muscle mass at all and if you look at Global Studies Asian Indians specifically have less muscle mass in every other ethnic group on the planet so for them I'm often starting with how

26:58    can we really add more muscle or more parking levels to that parking space I do have other individuals that come see me just like you mentioned and they're spending a lot of time lifting weights and barbells in the gym and they refuse to do cardio because again they're following somebody on Instagram or YouTube that says hey as long as you look you don't need to do a cardio but that muscle parking lot I'm oversimplifying things but I tell people there's two things we need to do number one we need to add more parking space

27:24    which structurally means we do need to build more muscle and strength but we also have to increase throughput we want to increase stability of that muscle to burn oxidize energy and create new parking space immediately after that and although definitely lifting can do that nothing is at more than increasing aerobic fitness your ability to just burn more fat and glucose in that muscular structure so people that are doing a lot of heavy lifting that's great they're adding parking space and they're clearly oxidizing energy because

27:53    you need that for weight lifting but they're not doing a lot of endurance work so we might just start off by adding more endurance work and then really identifying what factors in the diet we can help so as you know firsthand too A lot of people are doing a lot of dietary restrictions they're often protein deficient and I'm simplifying nutrition because often I find a lot of macronutrient issues first so I start with the macro first and then we'll get into micro type things like is it vitamin D or magnesium or other

28:18    nutrients that are important and again just because I have a general practice not a concierge practice I'd say the vast majority we have to start with macro moves like what is your form of exercise what can we do about macronutrients and then we can fine-tune other elements of the diet so I start with that and like you said in the beginning I really try to avoid restrictive because I'm not here to put somebody on a 30 or a 60 day plan I want to work with exactly how they enjoy eating and then can I sort of peel off

28:46    the a couple layers here and there so they feel like this is sustainable over the long term and that's a real critical thing to do is finding that path of enjoyability and sustainability when you implement these lifestyle plans yeah I think that's really well explained in um glad that that you mentioned a number of things such as kind of figuring out how to bring continue to have enjoyment in food and also enjoyment and movement and exercise and and uh that's something we've done a lot of time and invested a lot of time on

29:19    this podcast of making sure that we're not heading down that road kind of educating people on balance and and and these things and try not to kind of pull extreme levers and you know I think along those lines it would it would be you know helpful to kind of even back out a little bit further with the insulin resistance and talk about how you know sort of as life gets more com complex so what do you see getting kind of chipped away in people's lives where you know this store like when does that moment hit and I and I I don't like

30:06    when we kind of oversimplify it so much you know just say like oh it's when I got married or when I had kids or you know there's always those kind of explanations but what what is it like you're you're running around in your teens and them you get into your 20s what starts to shake the system up yeah I think it's just a lot of competing priorities as we look through our lives you know there is a time in our life where you know it's all about us sort of you know so we're focused on

30:38    school we're focused on education we're able to time manage enough priorities where we can focus a little bit on exercise we have the benefits of the Baseline metabolism that just does a better job of burning nutrients I mean I'm amazed at like when I look at because I've been tracking my numbers for a long time when I look at for example my CGM values or my cholesterol results and glucose in my body weight man in my 30s if I just cut carbs out even a little bit I can just lose weight no problem like my waistline would come

31:09    down no issues at all in my 40s that got just a little bit tougher but it was still doable like I could still be a very car again my tendency is insulin resistance I've had metabolic syndrome before which inspired me to do a lot of the work over 10 years ago but even my 40s I can get away with just yeah I'll just avoid a little bit of carbs I'll keep it at 100 130 grams whatever and and I'll be okay but then the minute I hit my 50s and I saw my patients aging along with me we realized that it's not

31:36    that easy it's not just cutting back the grams of carb by a little bit and exercising a little bit more all of a sudden I'm really being faced with the fact that um it is the total amount of food that I'm eating that has a huge impact and part of that is that we're not staying ahead of this race if we're getting incrementally a little bit more sedentary or a lot more sedentary because again we're not doing High School sports we're not in college you know we're not doing the usual Baseline

32:01    physical activities that we did throughout the throughout our lives if that's happening simultaneously with the gradual degeneration of our mitochondrial function so again I'm using the engine analogy of how efficiently the mitochondria Burns fuel if we think of horsepower we are losing horsepower with each year of our life and especially with each decade so this can be very subtle in the way it happens that life all of a sudden we're becoming a little bit more sedentary and now at the same time time or mitochondrial

32:30    engine can't burn fuel as much and then all of a sudden the net effect of that is coming back to that concept of over congestion where we're putting more fuel into a system that can't process that for energy and I'd say over the last few decades that drop has become more like a drop off the cliff just because of modernization of what we do at home and work this wasn't a case 50 60 years ago but you and I we've lived through an era where all of a sudden we're working mostly in front of screens where we can

32:59    doorstep deliver everything our incidental daily walking steps have taken a huge huge drop compared to where things were before and I've seen that in my patients with a pandemic is that I'm a big wearable guy I make patients get fitbits and track their daily walking steps and I've seen the fact that initially for example during the pandemic many people saw an increase in their walking steps I called it the honeymoon period where people were at work they thought about their own mortality they started getting outdoors

33:26    more but then after about a year and a half or two years into it when things really moved into more of like a a home you know work from home type environment I saw many people's walking step just drop off the cliff they went from 8 000 to 5 4 000 and as a result of that inactivity the mitochondrial function just starts to go down so so we're aware of a term called sarcopenia as we age our muscles start to degenerate we start to lose muscle mass on a molecular level I call this mytopenia where our mitochondria starts to lose its function

33:55    and we're losing those functional horsepower units as a result of our inactivity in conjunction with all of the nutrient stress that we're putting into the system now I can't remember if I answered your original question I feel like I went all over the place you did but it's kind of that stuff I think it was a transition to when when things start to you know happen right when the engine starts to fall apart a little bit so yeah yeah I mean it's great to to sort of know what we're up against as

34:21    far as mitochondrial aging and and also just the the socioeconomic climate we're in the obesogenic environment that the world has become so and and I I also share a lot with patients that literally every decade you kind of have to take a good hard look at your your current program your current lifestyle your current way of eating your current way of sleeping current we have Stress Management in in tweak and you know it's it's there's kind of a for most people a free pass for a little while and then it's

35:00    like okay you know as I say aging is what is it there's there's a saying about that that it's it's not easy that's the bottom line right so absolutely yeah um yeah so well that um I'd love to get more into Southeast Asian community and population and and what I what I see is as I care for a great deal of people from India and you know there's there's sort of this Trend that starts to happen in the 30s that brings up a lot of concerns related to metabolic issues and then there's

35:41    conflicts over dietary traditions and choices and messaging that they're hearing maybe in the United States versus the way families already always eaten and and there hasn't been these kind of metabolic problems before and so there's a big conundrum and a big struggle with my patients and I'm sure a lot of people who are listening to this podcast can relate so can you can you explain that to me or us and I know you already alluded to the fact of the lower muscle mass is there other layers to this that you

36:21    can share with us yeah so so yeah physical inactivity is a big problem culturally in this population um Just Sports and you know Sports is usually takes a very low second to academic performance professional performance so it's really not a big culture of you know physical activity and exercise and that's a big generalization but when you look at worldwide studies that even use activity metrics and they put kids and they put pedometers on them we always find that South Asians in particular they tend to

36:50    be the least active so that can have huge implications on mitochondrial function and this actually even goes back to parental physical activity levels so if Mom and Dad also were not physically active they didn't exercise regularly that really sets the genome in place for that child to probably not have as much of a robust metabolism and we see that right when you've got two athletes that have a child if they're Olympic athletes whatever you know if it's Steph Curry you know Etc they're going to have a different breed of child

37:18    than two software Engineers or two people that are purely academic who are not doing much physical activity and this is important to understand because when I speak to adults about this you know again I don't want them to go and blame their parents and get mad at them but a lot of it is what are the genes that we were dealt basically and now we have these genes in place the good news is we can do a lot of things to reverse that so the first thing is a message of Hope because I see patients for almost every generation or every sibling had

37:46    type 2 diabetes or something related to insulin resistance and they feel like why should I even try because I'm predestined to develop pre-diabetes or Diabetes by the time I'm 30 or 40 like mom or my sister and the good news is you know it's not just genes you inherit it's lifestyle patterns and diet that you inherit too so if you can be the one that takes physical fitness seriously if we can tweak your diet in ways that we're not parts of your cultural patterns we have a very strong chance of

38:13    reversing that pattern and that's really encouraging I don't get false hopes but in the majority of cases and you see this as well too when you've got that motivated South Asian or whatever ever you know ethnic group somebody just coming from a you know family history this rampant with chronic health issues it's incredible that within one generation if you implement different lifestyle practices that are aligned with the principles that we're talking about you can reverse the trend on almost all of that you know even my

38:39    patients that have had gestational diabetes they've often been told by their OB but you know what you're most likely going to be diabetic with your next pregnancy so just be ready for that but usually I find that that gestational diabetes was a result of how they went into that pregnancy and I'm like listen we have a second chance now with this second child we're going to do things differently and nine times out of ten they do not get gestational diabetes the second time around so so we don't want

39:04    to think of genes as being something terminal there's definitely things that we can do um so physical activity aside and then we really do a detailed nutrient intake to see where are the opportunities that we can take to really again prevent that flow of excess injury into the system and I've seen the early days Adam I was probably a lot more um carb fearful because I saw what that did to my body so a lot of my Approach was let's just cut the carbs down by 30 40 percent but nowadays when I'm doing a

39:32    little bit more over the last seven or eight years is is leaning more on just adding nutrient density in the form of proteins and healthy fats and other nutrients and guess what the byproduct of that is people will automatically reduce their carb consumption by a certain amount so what are the things that I can add instead of removing because we talked about the Arab restrictive dieting what things can I add to your plate they're going to make you feel better and they're going to prevent you from snacking within one or

39:57    two hours right what what's a breakfast that's going to sustain you for three to four hours based on satiety and then yes the end result of that is guess what you're not taking as many carbohydrates or other Foods you're snacking less and you're going to see a really beneficial impact of just doing that on the exercise front many of my patients that refuse to go to the gym and exercise we're just talking about the concept of exercise snacking how can you be more active during Zoom meetings you know how

40:23    can you take little breaks in between and just get the body of the muscles moving in very innovative ways while you're getting the you know all your work and your other responsibilities done so just starting with those two processes people start to feel better and then we're all driven by metrics and numbers and many of my uh South Asians they bring in spreadsheets right they're Engineers I've got 20 years of data right in front of me I'm sure you've seen that before and what I'm looking

40:47    for is quick wins like let's just check your triglycerides now for the next three months we're going to check it once a month and it's incredible that if they even stick to 20 or 30 percent of my advice they'll often see their tribe list price drop by 50 or more points now they're bought in they're like wow I haven't seen this in years what do I do next I feel a bit better an intro twos off my waistline now what do we do to motivate them okay can we modify your dinner a little bit or let's switch out

41:11    your snack or maybe we'll do one time a week of 30 to 40 minutes of aerobic endurance some patients honestly are super motive they want to do everything so then I'll throw the kitchen sink at them and see what lands but others I've got to be very incremental and then we've got to track the numbers that I know are going to respond most quickly and those are numbers like triglycerides maybe put a glucose sensor on them so they can see the immediate impact of their lifestyle on diet on mitigating

41:36    persistent glucose elevations Etc so using data encouraging messaging you know sensors to maybe keep track of them this combination seems like it works really well in folks that's great um I love how you started the answer talking about how being focused on changing you know familial Trends or familial Health patterns by you know sort of taking charge of diet and lifestyle I really like that message and it it's really refreshing to hear that you're not asking necessarily to to change cultural diet or cultural Foods

42:16    it's more about eating more nutrient Rich aspects of those Foods so for example you know I I mean while you're speaking I was thinking lentils are just tremendously nutritious food and a big part of Indian cuisine Are You Are there specific Foods or traditional foods that you emphasize and to kind of get some of the more Carby sugary stuff out yeah so you know obviously there is that there's going to be a different approach to the vegetarian Indians versus the non-vegetarian Indians with the non-vegetarians it's much much easier

42:57    because they're consuming chicken fish they're getting the adequate protein which most of my Indians aren't getting um but you know my vegetarians refer to focus on that again you know in the early days I might have been a little bit lentil phobic as well too because as much as we're getting protein you know the carb intake the carb content and lentils can be quite significant but now really what I'm doing is because lentils are such a great source of B vitamins other nutrients fiber Etc it's really

43:23    looking at the plate and putting the right combination of foods together so for example if it's you know a lot of my patients that are just doing Dal or lentils and rice and they're having a flat bread it's like in that one meal they're eating over 100 150 plus grams of carb in that just that single meal so what can we do if you really want to have the lentils let's have the lentils with a good vegetable based Curry and the nice thing about Indian cooking is they do a wonderful job of making

43:50    beautifully tasting vegetables right that's why a lot of vegetarian restaurants use a lot of Indian recipes because there's so so many amazing vegetables we can eat so now you've got some protein from the lentils you've got a nice bulky vegetable based um Curry and then with that if you wanted to have something Dairy based like a paneer or you know you know so my patients I'm getting them to maybe consume tofu or some other protein source and they're able to incorporate that or if they're

44:16    open to eggs other protein sources they do find but if they mentally keep track of the fact that they're not getting every single food group is from the carbohydrate family in addition to the fact that they're not physically active that's really going to be a you know process of over nutrition with that adequate energy expenditures so when they start doing Pro you know mixing and matching proteins with the proper carbs they can still enjoy their favorite foods and do well the other thing obvious is you know there are a lot of

44:43    healthy fats you know or that neutral type parts of the diet so you know he obviously has a lot lot of health benefits but I do tell some patients to be a little bit careful because some people are overdoing key and we might sometimes see their LDL cholesterol go up but it also has some ayurvedic anti-inflammatory healing properties so so if you look at a lot of the dietary Trends often we are using a lot of the traditional spices like turmeric we might be using ghee or coconut oil to some degree so I remind a lot of my

45:09    Indian patients that guess what this is native parts of our diet that we can incorporate but let's not do like a carb bomb for each one of our meals especially when we're Physically Active because that's going to be a big issue in the long run so excellent well I want to finish our conversation with a few quick hitter questions and and then maybe kind of turn things over to you and hear more about your podcast and some of the programs you're doing and kind of wrap up with that because there's just so many great aspects of

45:39    your work and I absolutely love your podcast I want to make sure our listeners hear about I hear about what you're doing with that so quick header questions I have like the first one is if you were to get a metabolic scorecard for each of your patients and say for people with just like average income level maybe have access to health insurance what would be your scorecard like what tools would you use what measurements would you get that pretty much most people listening to this would have access to yeah so I

46:17    think it is important um for everyone to get either a standard or an advanced lipid panel um I know there's a big push in sort of the health and medical world now to move towards Advanced lipids and I think they can really provide some additional useful data but for most of my patients just starting with the Scandal standard cholesterol panel we can get a lot of information from that but really paying attention not to just the numbers like the total cholesterol not just to be LDL but like I talked about earlier focusing

46:44    on that triglyceride in hql making sure your ratios are optimal so for example if you take the triglycerides divided by HDL you want to get that ratio low less than three would be a start but even getting it to lesson two would be even better so that's a standard lipid panel then you know the glucose obviously we have the hemoglobin A1C test and that's a useful test to get an average snapshot of your glucose over the last two to three months you know fasting blood sugars as much as I order that as a

47:11    standard part Channel I feel like passing blood sugars are very very difficult to interpret because you know I have very metabolically healthy patients that just tend to run a 105 when they get up in the morning and it really means absolutely nothing at all because they're A1C their average sugars their CGM values are okay so I do tell people just a grain of salt when you check that fasting blood sugar because some people might have a slightly elevated belly in the morning and it's not symbolic of the fact that they are

47:37    truly pre-diabetic or they have impaired fasting glucose especially if they're overall diet and lifestyle plan are fine but that's another test we check now fasting insulin I think is getting a lot of press I have used fasting insulin not routinely it is relatively affordable but I do have some disclaimers around fasting insulin because some people feel like if their fasting insulin is Right within range then you know just based on some of the podcasts you've been listening to they feel like they're not

48:02    insulin resistant but I do have plenty of patients that have other shondivincent resistance and their fasting insulin is actually normal now when fasting insulin comes back really high it's in the High Teens above 20 that probably is an indicator that you are insulin resistant to some degree because coming back to that parking lot analogy your body is having to produce extra insulin to push the nutrients into muscle and other sites so that's another test so we've got the glucose we've got the lipid metrics possibly insulin and

48:31    then the body metrics really um in order to really identify sort of body metrics I think the waist to hip or the waist to height ratio is a really good way to go the waist to hip ratio has been around much longer so basically taking your waist circumference dividing it by the hip and you can look at tables online that stratifies it by different culture groups another way is to waste to height ratio basically so you basically take your waist circumference and your height you divide the two and in general your waist circumference

48:59    should be about half of your height or less rough rule of thumb there but again when you use tables and standards like I talked about earlier you want to really combine that with those other metabolic numbers to see where you scan so if I have the patient where all their lipids and numbers looks great but they still happen to be 15 or 20 pounds heavier than the table or their inches might be one or two inches above I'm actually not worried if they're feeling great and they're staying physically active they

49:25    might have a cosmetic goal they want to strive towards that's up to each individual but I'm pretty happy if their energy endurance or strength their Fitness and metabolics are fine and they happen to be carrying some of that extra weight but that's kind of a starting point of the labs that I'd start with and then the next layer beyond that is yes maybe incentive individuals will do decks of body scanning to see body composition Etc the last thing I would add is I don't do this routinely in

49:49    everyone but in my individuals my patients that do have signs of insulin resistance we're trying to make a decision around whether they need to be on medications like statins or so I do have a little threshold for checking an inflammatory test called the hscrp or the highly sensitive c-reactive protein now on top of that I am blessed in my Medical Group because if I see other signs of systemic inflammation gut disorder things that you treat so directly I might refer to my integrative colleagues like our common friend Dr

50:18    Akil um who is obviously an excellent position he's got colleagues as well so we might go that next layer but I love the fact I don't think everyone's ever asked me what are accessible and affordable ways we can handle this I can get asked a podcast for people that feel like every patient has a blank check and they can write whatever amount for their testing but this is a real prohibitive thing for our patients is you know the cost of some of these tests is prohibitive and really Beyond a certain

50:42    level those additional tests don't necessarily add that much more value so yeah I mean I find the more affordable tests also have way more data behind them so true it's it's easier to feel confident with some of the decision makings if you're going to try to use that data like look at that yeah I would love to if we have time just a quick comment on April lipoprotein B is a marker yep yep absolutely do you want me to dig into that now yeah I just would hear like if that's part of your your thinking or if that's

51:17    still something that's you're you're still considering yep yep yeah so one of my colleagues I'm sure everyone knows him because he's the world famous now Peter attia obviously has been pushing APO B for quite some time and and me and Peter had a lot of conversations a few years ago where we'd talk a couple times a month basically to discuss South Asian patients and insulin resistance and definitely at that time I was ordering Advanced lipid panels the April B I think is an absolutely useful test

51:42    because it is true that one of the many factors that can drive heart disease are the number of LDL particles that you have in the blood and the Apollo protein B is a test that can more reliably sort of tell you what is the amount of that LDL particle or I'm sorry I should say the APO B particle traffic that's in the blood now having said that even without doing that test if I have somebody that has triglycerides above 250 300 or they've got a high triglyceride HR ratio I can bet my money that they've got

52:11    increased LDL particle traffic I don't need to get an able B to check that so I'm already going to implement the same lifestyle changes and advice that we've been talking about without having to get that April B test on the other hand I have some patients that look metabolically fine their numbers are fantastic you know everything's looking good they're exercising they're doing everything great and getting an able B doesn't necessarily add that much more to my implementation plan now if they

52:37    have a significant family history of early heart disease Etc we might do an lpolay and an ape will be on top of that so I'd say in most of my patients we might check a baseline open B at some point but um I just want to get away from a sinking that gosh if we don't get an APO B we're doing a disservice to our patients because I would say that you know there's enough other signals that tell me that okay this person's insulin resistant High cardiovascular risk even without me having to check an apob but I

53:03    do agree that now that these tests have become affordable accessible at some point these might end up becoming the gold standard which I think makes sense in the long run excellent thank you for for explaining that so yeah I'd love to wrap up here I know you have to get on to another conference and just would hear some like to hear some closing thoughts and if you could share our audience about your podcast your course courses and anything else that you'd like to share and so that people can follow you and get involved

53:30    with your work yeah sure I mean I I think what I appreciated about this conversation is we stuck to just the basics and keeping things as simple as possible so I think one big message would be really be aware of the noise that's out there it's a very noisy space around health and wellness and really again I'm not being over critical here but a lot of our colleagues in the health and wellness space they are driven by a lot of material incentives to sell supplements to do more advanced testing on a regular

53:59    basis um to maybe make Health seem more complicated than it is and I just want people to be aware of that and now with the integration of AI Technologies and chat Bots guess what people are going to be putting out a lot more content and they're going to use image modification to show that they have a six-pack a lot of before and after we are literally about to enter an era where you're going to be inundated with even more information so so I think it makes a lot of sense for people like Adam and I to

54:24    really just stick to the basics and I'm not sure changing honestly I don't check APO B's in myself every three months I don't do most of these other tests that people recommend ending online so sticking to the basics I think is really key now my resources are really focused on that that's why I really try to teach people about metabolism in detail so my podcast is called the meta health podcast and I dig pretty deep and I use a lot of Storytelling and imagery to teach you these Concepts and part of

54:49    that is because I want you to appreciate the wonders of the human body because it's incredible what our body is able to do but it's also so you can be a discriminating consumer of health information and make sure you're really not being oversold products that you don't actually need so MetaHealth podcast is one place but I think the best resource to go to is just go to my blog at cultural health solutions.

55:12    com I do write blog posts Sarah you can link out to my medical podcast I'm also on social media on Instagram at ronishen MD but you can find all of that stuff when you go to my website at culturalhealthsolutions.com I think that's good excellent thank you and I say this to my audience that your podcast is the first podcast that I've literally said to myself I want to listen to every single episode oh that's okay yeah it's I just I feel like it's a master class in all these things that we talked about

55:43    today so if this Rings anybody's Bell with you know the things that you like to learn and the important I mean it's important for all of us to learn this and just the fact that you walk us through bit by bit step-by-step concept by concept and use ways that we can understand is so helpful so thank you for doing all that and thanks for coming on today and and uh spending time with us a pleasure thank you for the work you're doing too Adam you take care of yourself all right bye-bye thank you so much for tuning in to this

56:16    week's episode of the one thing podcast please share these episodes with your friends loved ones colleagues patients Healthcare Providers anyone who you feel might benefit from hearing these informative interviews we tend to learn best from people sharing things with us that's often the first time it's introduced so don't hesitate if these the content of these episodes reminded you of someone that might benefit from it for the the episode to them and I'm sure they'll either appreciate it or be

56:49    appreciative that you've thought of them so once again we'll look forward to seeing you next episode on the one thing podcast and again much appreciation for you being here with me [Music]