 Well, hello everybody. Welcome to another episode of Dr. Jill Live. I have a new friend and guest, Dr. Ron here. I'm going to introduce him in just a moment, but you'll know if you want to find further episodes, you can go to my YouTube channel, you can go to iTunes, Stitcher, or wherever you listen to podcast. And please, if you're enjoying the content, stop by, leave us a review, share it with your friends. Today, I have the honor of a new friend and have been so excited to meet him. We ran in the same circles and just lots and lots of beautiful things that I've heard about him. And today I'm going to be getting to know him better along with you. Dr. Rani, how do you say your last name? I should have. Yeah. Thank you. He's the author of The South Asian Health Solution, an internal and an internal medicine physician who runs a lifestyle clinic in Silicon Valley focused on reversing insulin resistance in ethically diverse patients. He's also an expert corporate wellness, an expert in corporate wellness and serves as chief medical officer for the Silicon Valley Employer Forum where he serves as global advisor, shape health benefits for over 60 major Silicon Valley companies. His groundbreaking work in corporate wellness and raising awareness about insulin resistance in the Asian population has received global attention with the front cover stories in Fortune magazine and LA Times. He blogs actively on health at culturalhealthsolutions.com and recently launched the Meta Health podcast where he uses creative storytelling to teach listeners about health and metabolism. Welcome, Dr. Ron. I'm so glad to have you here today. I'm so excited to be here as well too. Thanks for having me. You're welcome. And I always like to start with story and like how in the world did you get to where you're at? Were you born out West? And how did you get into medicine? Tell us a little of your backstory. Yeah. So I was actually born on the East Coast. That's where my early childhood was. And then I came to Central California for fourth grade. And as I was going through my schooling, this is actually not very inspirational because I actually did not know what I wanted to do with my life. But being from an Asian Indian background, especially back in those days, there were three options. You become a lawyer and engineer or a doctor. So I basically, even though when I went to college, my heart was more into writing and creativity in English, you know, kind of immigrant parents were saying, well, you need to have a stable career. My older brother didn't go into medicine. So kind of the pressure fell on me. So I actually went into medicine just by, you know, just by default mechanism. So I got to tell you that when I was actually in medical training, medical school, I felt like an imposter in many of my classes and rotations. I'm like, do I really belong here? And even when I started medical practice in Southern California, I moved to the Bay Area, it took some time for me to get my feet wet and realize, wait, this actually is something I'm pretty passionate about. And, you know, as I kind of raised my own kids and I sort of looked at the community, it's interesting because I think there's this expectation that kids should be passionate about what they're going into from age 12 or age 14. And I think it's kind of a high expectation you put on kids because you kind of grow into a lot of your passions. But what happened to me was, so I was in my primary care practice, and in the Bay Area, I started seeing a lot of people of Asian Indian descent that were coming in with really, really high heart disease and diabetes risk. And I realized that our medical group was providing very generic information, like used a Mediterranean diet, and then how do you tell an Indian vegetarian that the Mediterranean diets can actually help their situation. So what happened was, I started helping my medical group develop a website and resources that were really more culturally tailored for the population and the Asian population at large. And that kind of checked out the box of, wow, I get to do some writing and some creating here, which I didn't quite get to do during medical training as you know firsthand. It's a very left brain memorization recall type training process. And that kind of set in motion the fact that I could serve a community, use my scientific background, and use some creativity to do lectures, to create programs, to do podcasts, to do writing in very creative ways to sort of, you know, help educate. And that really became my passion. I realized my real passion is teaching people, teaching students and teaching the public to really digest complex, you know, scientific concepts, so they can make empowered decisions about their health. So that's kind of where I ended up now. And the company, the corporate side of it is my medical practice was right next door to Oracle and really in the heart of Silicon Valley. And I realized that a lot of the patients I was seeing were desk-facing sedentary workers that were developing really early disease. So I started going out to the companies to give lectures, but I really added that cultural flavor so I can connect better with a diverse audience. So fast forward to now. So now that's been sort of a key part of my job is to really go out to these companies and teach people how to be healthy and well, just by working from home, being sedentary and having so much job pressure. And how do you really add a cultural layer to it? So people can understand what their individual risks are. Because as you know, the risks really vary amongst different ethnic groups. African Americans have different risks for heart disease. Asians have different body mess and criteria, ways to circumference criteria. And if we give people all the same vanilla risk guidelines and advice, we're actually going to miss out on a lot of disease, which is what I was seeing in my clinic. So that's kind of a broad overview. Wow. I love that because the first thing I heard was kind of my experience in medical school too. I was like this artistic, creative, very intuitive being, and I was born into a family of engineers and there was no other doctors, but a similar path in the sense that I went to this institution, which is very analytical, black and white, kind of if you think about energy is a little bit more masculine than the feminine, creative. And again, there's nothing wrong with these things. We all have every part of this in ourselves. But I kind of like felt a fish out of water too. And like, okay, how do I actually like, and what I did first was kind of suppressed that other side of myself to get through the brutality of medical training, right? And then there's this piece inside this, like, wait, is there more? And what I love is you've used your passion and creativity. I think that's the best of both worlds in medicine is how do we really transform the practice and even I've been talking about because of the book that just came out that I wrote was about how in medicine, a lot of physicians are really, you're trained to kind of ignore your needs and be very driven. And it's such a black and white model. And I don't think it creates very creative or compassionate physicians that come out, right? It's like, we're brutalized into ignore your need to pee, you retract a surgery for six hours and like ignore your need to drink and sleep and like not taking care of yourself is actually doesn't create a very compassionate, creative outcome. So I already love that story because what you've done is you've like, okay, take that great education that we both got. How do we go into the world and transform it and meet people where their needs are? The second thing I heard was amazing because you saw this population that and I've seen this too, you go on Instagram or social media and everybody should be carnivore. Everybody should be keto. Everybody should be vegetarian. And I find I'm so open because there's no one-size-fits-all, right? There's no one-size-fits-all. We definitely have to add about whole foods and good foods and like, you know, organic if possible. But let's talk a little bit about that because I find that to be such a conundrum. A lot of people in our world are saying everybody should be this way or again, keto paleo were popular. Those can be appropriate for certain populations. But then when you have someone who's, you know, keen law based or rice based, tell me specifically more about, you know, this Asian population and what you came across because I think this is valuable information for all of us. Yeah. So, you know, if we really bring it down to the essence of energy, and I totally agree. I feel like we have a pure support group. I didn't realize you emotionally suppressed yourself through medical training. Totally. Totally. I knew you back then. Now I have my purple hair and like this would have never gone, right? Like rebelling like so many years later now. No, totally. Absolutely. Yeah. But to answer your question, it's true. There is, it's almost like religion when people talk about their dietary preferences and it can lead to a lot of tension. And I even have people in my audience that maybe decided that they were going to go plant based and vegan. And they really reach out to me and said, you know what? I think your information is wrong because my life got transformed. I'm like, I'm so happy your life got transformed. And I really don't care if it happens through my you find your own avenue. But the fact that you took control of your health, that's all that matters. But, but the way I think about it is again, talking about metabolism, we just think of food as being energy. And at a very high level, all we want to do is make sure that your body can appropriately use that food energy and really power all the different resources in your body. And that energy can come obviously from carbohydrates, from proteins and fats. And it's at that macronutrient level, which a lot of the battles start to happen, low carb versus, you know, low fat and all things. But really what it comes down to is at some degree energy intake. And in that Asian population, what I was finding is that the carbon, the relative amount of carbohydrate intake was very, very high. And if we think of the mitochondria, again, that's a power structure in sugar cells that converts food to energy. If there's a relatively large amount of any of those macronutrients, especially fatter carbs, it overwhelms the system. And once the mitochondria is overwhelmed, it cannot function properly. It'll divert nutrients to fat, to liver and cause all types of issues. So in this population, I was seeing a lot of rice eaters, a lot of flatbread eaters. I've nothing against lentils, but if you add a lot of lentils with the rice and the flatbreads, you've got a cumulative carb overload. So that was the big message. And when I wrote the book and I started the process, you know, nutrition can be so complicated. And I hate it to be that sort of, you know, to simplify that much. But I'm like, that literally is the lowest hanging fruit. So I need people to understand insulin resistance in the context of carbohydrate intolerance. And that was really the big thing there. Now the interesting thing is, as many of those patients have gotten healthier, they've literally added mitochondrial horsepower is what I call it, because now they've got more engines are functioning better. So somebody who was rice intolerant, let's say five to seven years ago, and I kind of treated rice as a taboo food in them. And initially, now they are actually physically active enough and healthy enough, where rice is an incredible source of energy after their three mile hike, or after they've done a hit training session, etc. So a lot of those foods that might have been not appropriate for them at one stage of their life, they can evolve to actually adapt to those. So, so that's where, you know, again, I have some patients that are elite athletes, they're not of Indian background, they're Olympic level athletes, and I'm not sitting there counting their carbohydrates at all. We have doptomizer, rarest, their recovery, their training, and just the overall balance of nutrients. But, but I think that's where the nuance is. And so somebody who's really benefiting from low carb keto, good for them. But that doesn't necessarily mean that that diet is going to be appropriate for their brother or someone else or you can't really generalize and extrapolate to other people because their genetics are different, their energy needs are different, their risks are all different. So hopefully that's kind of unifies things a little bit. So, yeah, super helpful. And one thing that I thought about too, as you first introduced, you're in Silicon Valley. And when you started really working with these people, they're all sitting at desk, they're probably extremely high stress, extremely driven, type A. And that because it drives cortisol and insulin is part of this whole picture, right? Because you're if they were in their native environment and we're, you know, growing food and harvesting food and you know, like some of like 100 years ago, all of our grandparents or 200 years ago, versus in the Silicon Valley or in Chicago or in New York City. And this that makes the difference too, right? Because they're sitting, they're sedentary, the stress level is high and tell us just a little bit about for those kind of new, because this is relevant for everybody. What happens when you're very sedentary, high stress to the metabolism and to the risk of diabetes in this whole high cortisol situation? Yeah, great point. And even before I dig into that science, I love the fact that you brought that up, because one of the experiments I've performed over and over in my patients is as much as when they are in their high stress parenting work lifestyle that sedentary and really driven, you know, they might be quantifying their carbohydrate intake. And they literally find that, you know, a lot of my patients, we can talk about this later, I put a continuous glucose monitor on them. And they find that they're if they're exceeding 100 and 150 grams of carb per day, their glucose is just very unstable. And it's all over the map. And they're having to do a lot of things to help manage that. The interesting thing is when a lot of these patients go back to their native country, like for my Indian patients, they go back to India, where they might be in a non in a more rural part of the town where their family is, they're really not paying attention to the carbon take, but they knew intuitively, they're probably eating three times more carbohydrates. And guess what? Magically, they lose some weight. Some have actually wore their CGM and their glucose is so much more stable. And exactly what you said is if you've got all these other inputs of sleep disruption, you know, circadian rhythm, and high stress and all this stuff, and the food's not being as natural as something that their grandmother or their mother's preparing there. It really has such an incredible impact on metabolism. And early on in my work, I kind of thought of those as something on the shelf. You can directly impact that. But boy, when you put a glucose sensor on and you see what happens in the midst of conflict or any of these stressors, you realize that the emotions that go inside that head are as important as the food that goes inside your mouth, right? So it is so powerful. So you're absolutely right. That becomes a big factor. And then the specific mechanism as you brought up, definitely what cortisol does do. So if we think of food and nutrients is having different destinations in the body, carbohydrates in particular in an ideal of metabolism, we'd want about 80% of that carbohydrate to go to your muscle. So your muscle can use it and store it if it doesn't need it or burn it and use it for energy. But when you've got metabolic dysfunction or insulin resistance, that carbohydrate, all of it is not getting to the muscle. I call it the muscle parking lot. I tell people cars are like a car. So that car is getting diverted to fat cells or it's going to the liver. And then the liver can store it and turn it into fat or pump it out as blood sugar or triglycerides. So cortisol, what it does do, it's an additional input, again, the stress hormone that can divert that carbohydrate energy more towards deliver and accelerates the process called gluconeogenesis where the body converts starches into glucose. And cortisol has a very powerful impact on that. So many of my patients interestingly, and I'm sure you see this in your clinic, some of them are very low carbohydrate, they're ketogenic, etc. So if we were to explain this just by being carbohydrate phenomenon, there's no reason why their morning blood sugar should be so high, why their average sugars are so high because it's not based on their carbohydrate intake. But the minute we realize it, it's their stress and actually even nutritional stress because they're not necessarily enjoying having to restrict your carbs to be socially disconnected because they're like, God, I don't want to go to a social gathering because you're going to have a bunch of carbs there. And I just don't want to be there. All these other things are actually causing more metabolic stress to the body than the food they're actually consuming. So it's a really, really important point that we need to keep emphasizing. Hey, everybody, I just stopped by to let you know that my new book, Unexpected Finding Resilience Through Functional Medicine, Science and Faith is now available for order wherever you purchase books. In this book, I share my own journey of overcoming life-threatening illness and the tools and tips and tricks and hope and resilience I found along the way. This book includes practical advice for things like cancer and Crohn's disease and other autoimmune conditions, infections like Lyme or Epstein Bar and mold and biotoxin-related illness. What I really hope is that as you read this book, you find transformational wisdom for health and healing. If you want to get your own copy, stop by readunexpected.com. There you can also collect your free bonuses. So grab your copy today and begin your own transformational journey through Functional Medicine in Finding Resilience. Well, gosh, so brilliantly said. And I think my thought is like the cultural diets that you're dealing with back in the day, in the culture, they might have been perfect. And that's the difference here is all of a sudden we take, you know, and everything's Americanized, so even in these very rural places, they're getting more McDonald's and some of these things. So I think the beauty of it is culturally, some of these diets were absolutely perfectly balanced for that culture as, like you said, the grandmother harvested the grain. And you know, we find this, I love to add Dan Buehner's work on the blue zones, because what he's shown is like all of these centagenarian areas, you know, Italy, Greece, Japan, a lot of them are very high carb. Like their main sustenance in Japan is, I think, some sort of a sweet potato in soy. And then, you know, in Greece, it's like, I may be saying this wrong, but it's like rice and corn and Costa Rica gets corn. So they're in our Americanized world when it's very processed, those things as corn tortillas or whatever would be in the stressful environment, totally wrong. So I love that we're talking about there's this macronutrient thing that's key, but it's really reliant on the stress and the environment and even the quality of food, because sadly in the US, everything is so processed, so sprayed with pesticides. And these things affect metabolism as well. True. You know, even my relatives that literally come to visit me from India, like when they come here, it's incredible. Like doctors, like within a few days, they gain tremendous amounts of weight. And it's not that they're eating that much more food, but you start to realize like that blend of all the stuff that's put into the foods that we eat, we go to restaurants, etc. It is just very different. And even like, you know, my relatives are non-vegetarian, they eat meat and fish, but hormones, you just realize that milieu of different things is really doing something different to the body that we don't clearly understand, but it's clearly not benefiting our body in any way. Right. Right. And then like, how do we live in this toxic world? Because we are all our sweet, right? Yeah. And I think the interesting thing is, I think people that have grown up in this toxic world, I'm not saying they've adapted fully, but it seems like it has a little bit less of an impact or maybe it's stretched out over a longer period of time. But when I see immigrants come here from China, from India, etc., because they have sort of maybe some microbiome, I mean, because they're conditioned to that native environment, when they're exposed to Western foods, like within that first year of immigration, it's kind of like the freshman 15. Literally, I see like the freshman 15 for immigrants where they become full blown diabetic, they gain just enough weight to throw them over the edge and develop fatty liver and all these issues. There's something really in cities happening in us. And a lot of us have been, I was born and raised in the US, you know, so maybe add more of a gradual toxic exposure. Not that I'm saying that's good, but for people where it's more abrupt, it really can have quite a dramatic impact. Wow. And that just goes to show, because I've been studying glyphosate application, a group on a farm and all these things that I know like the wheat in the US is number one, bred to be higher gluten. And number two, it's almost always unless you're getting organic certified, it's sprayed with glyphosate, which affects. So I'm wondering, yeah, this load I think really does affect. So sorry to get up on the tangent, but I think actually, I'm glad you brought that up. And this is your area of expertise. So I'd love to ask you, because I do see, for example, a lot of Indian women that have significant issues with gluten, they seem like they're gluten intolerant. A lot of them have Hashimoto's thyroiditis. And the interesting thing, again, is when they go back to their native country, when they consume the flatbread tortillas and the chapatis, you know, all those things there, they don't have the same bloating and the same effects. They feel like they can tolerate it better. So, so absolutely, this is kind of my experiment, like native country being in the West, I'm seeing this going back and forth, and I've been seeing it for over a decade. So, so I think all of your insights around, you know, the, the, you know, the pesticides and the gluten load and things, those are definitely having impact for sure. It's fascinating. You know, Stephanie, Senna did some work and she was postulating that number one, the gluten is almost always more, more likely sprayed with glyphosate. So unless you're really careful, you're getting that roundup as well. And it actually changes the protein structure. So it makes it more antigenic to the immune system. And her correlation was children with autism and celiac disease was a massive rise in correlation with the spraying of the wheat. Who knows if it's an exact just correlation or not. But it was interesting to see, and I bet there is, because I've seen the same thing where people are, you know, Americans go to Europe and often they can eat, right? So true. They're in Italy and they're walking steps and they're eating way more carbohydrates and they feel good and they're not getting weight at all. So there's something to that. So fascinating. So continuous glucose monitors are super popular now and you've been using these, I know, with your practice and tracking people for a while. I think it is really helpful. My family actually has a strong history of diabetes. So my brothers and stuff have all tried that and they were all kind of shocked at, oh yeah, like rice, you would think that's a pretty healthy food, really raises blood sugar. What have you seen that be? How powerful is that for patients or people are listening and like either I just got one or I want to get one. What would you give them as far as advice on how to use that? Yeah, you know, so after running programs, so literally my medical group right now, I'm actually running scalable programs with several hundred people in them. So what we do is we prescribe sensors for them. I don't actually interpret their data individually. But because I've looked at this data for so long, we teach them what those average numbers mean. And one thing I want to say off the bat is as much as they've been really touted as being like a miracle and their incredible kind of tools and sensors and I'm a big fan of them, but they can actually cause a lot of irrational anxiety because glucose spikes are just all of a sudden demonized. You need to eliminate all glucose spikes. Have apple cider vinegar before every single meal. Why is your glucose going up after you to banana or something like that? So I just want people to know that glucose spikes are expected. That's a normal biological function so that's one thing you need to keep in mind. But what we need to start acknowledging is not just a glucose spike. The first thing is when you put the sensor on, yes, what's the magnitude of the glucose spike? And even more than the magnitude is how long is that glucose spike actually lasting? Because really if you have an optimal metabolism, again coming back to that image that I gave you of that carbohydrate car, efficiently the muscle clearing it out of the system and a really solid metabolism when your glucose spike goes up, the muscle should very effectively clear that glucose out of the system. Now, if you look at studies, if you based on diabetic data, yeah, you'd expect that you'd clear up by two, two and a half, less than three hours. But if you look at young folks with optimal metabolism and no signs of instant resistance, and in many of my patients that have reversed their diabetes, they start off maybe with a two hour glucose recovery time again from spike back to baseline. But as they get better, they're gradually coming down to 90 minutes and 60. So in many of my patients, it's between 30 to 60 minutes. And even if they have something that's high glycemic, you get that back down to range. So that's sort of key to look at. The other factor that you really look at is how much glucose variability are you having throughout the day? And this is a really big issue in a lot of my women in particular, because when they go see their doctor and they get a regular glucose for an A1C test and the A1C being your average sugar that lasts two to three months, often they see that their number is normal or it's on the low side. And they're told by their doctors, you're great. You're far away from diabetes. But one of the reasons they're actually low is because they're getting so hypoglycemic. And that's what the CGM picks up on is the fact that, my God, every afternoon, your glucose is crashing by 60 to 70 points. While you're sleeping at night, we're getting frequent hypoglycemic episodes. So those lows are actually pulling that average number down. But coming back to cortisol, if you're having that much glucose variability with that many relative hypoglycemic episodes, that's going to be a big strain on the brain, the body, the metabolism. And studies actually showed that a lot of glycemic variability is actually atherogenic. It does things to the blood vessel wall that can actually trigger more plaque formation. And also glycemic variability can be a predecessor to developing prediabetes and diabetes later on. So I know you and I have a very preventive, proactive approach. We don't want to wait for patients to become prediabetic. I'd rather catch them as soon as possible. And so CGMs, we can pick up on those early signals. But I think the key thing right now, and hopefully this is going to shift, most doctors aren't comfortable prescribing them. And they may not know how to interpret the numbers. And quite frankly, they're just too overwhelmed. I'm being a typical doctor in today's age, like 15, 20 minutes per patient, they can't consume glucose data on top of that. So there's a lot of companies out there that are doing that. We're trying to do some stuff through healthcare systems. But I don't want people to wait for that time to come. You can still learn quite a bit by putting the sensor on and making some rational changes. And the last thing I want to say is to make glucose sensor is one of the best activity monitors out there. Because when you see that spike, and you go for a 10 or 15 minute walk, you often will see that glucose number come back down to a really reasonable level. And that's really powerful. You don't have to break a sweat. Just put on your walking shoes and walk after that pasta meal or whatever. And you're going to see that glucose come back to a much more stable level. Brilliant. I'm just in awe here, because there's three things I was thinking as you're talking. You just covered all three. Number one, as a physician, like myself in practice, this is amazing data. And I want to empower the patients. But for me to read it is a little overwhelming. So I love that you're talking about that. And I love that we're empowering patients to be their own advocate in some ways. They don't have to be the experts. But if you're out there listening, you've got one you can learn. And you can do some of this yourself. So I love that. Number two, cortisol. I'm on the other end of the spectrum, which are much lower cortisol. And I tend to go on the low end of glycemic index. But in my thought was I have in my cabinet a two weeks trial on the glucose matter. I haven't put it on yet. It's like, oh, I'm fine. And you just like encourage me. I'm like, I'm going to go put that on because I bet you anything I'm dropping. And again, my A1C is fine now, but that's strong families through diabetes. And like you said, I guess for those listening, if you have really low cortisol, you may be on the opposite end of the curve. And the other helpful thing of this is not that you're going to have to watch, you can still spike after meals. But the bigger thing is how often are you going in the 60s or 50s and feeling miserable? And it's all blood sugar related. And then how do we eat to really sustain that? Because my go to, if I'm feeling not very well, kind of weak, I might grab some dried mango. Well, of course, that's high glycemic, right? And I think I can afford it. But I, you've just encouraged me, I'll say this live on the air. I'm going to go do that. I'm going to imagine I'll be happy to coach you through any of those numbers. You know, it's funny because whenever I'm in tech circles, people always come to me and say, God, when are we going to invent a continuous cortisol meter? And that'd be very difficult to do. But someday we'll probably have that. But until we have that, I actually think the glucose sensor is kind of a subtle surrogate marker for cortisol levels. Because we do see, again, like I brought it before, I want to give one anecdote. I had somebody from my team that put the sensor on. She had rock young woman rock stable glucose. I mean, I've been tracking her data. And then basically this is during COVID, she went to dinner at her in-laws and had a conflict with her in-laws about the COVID vaccine. And her glucose literally went up to like 180. She'd never seen that number at all. So then just because she knows of my work, she came out, she did some reframing. She did some breathing in the patio. She came back and she watched her glucose come back down. And then they all had chocolate cake together for dessert. And her glucose went up to 130. So I did a blog post on that saying how your in-law can be more dangerous than chocolate cake. But to make the point that it's just incredible about like those types of conflicts can just cause so much. So yeah, it can really get people to actually track that. And speaking of dietary stress, we get a lot of people in our programs that are doing a lot of intermittent fasting and a lot of restrictive dieting. And this is actually motivated because when they see that glucose tank and they're wondering why am I getting snappy with my kids? Or why is my life experience different after 2 p.m than it is the first half of the day? Often we see that glucose drop can be a big factor. And so now they might actually start, I tell them, maybe don't start eating at 12. I think you need to start eating at 9 or 10. It's interesting how we try to get everybody the same. But there's so much variability hormonally from an insulin perspective. So we do have to kind of play around with that. And that's why I like the sense or like I think the concept of time restricted eating is powerful. But you may not be one meal a day person. There's a big OMAD move where people are just eating one meal a day. And that's not right for a lot of my patients. They've got to add more meals. It's definitely not good for cortisol issues as well too if you're basically just having one meal at the end of the day. So gosh, this is so in line with what I again, I don't I don't have all the data on using continuous glucose monitors or the experience you do. But my thought is in general, I often see women menopausal or pretty low cortisol that probably shouldn't be doing intermittent fasting or at least not to the extent that they're doing it. It sounds like that aligns as long if their cortisol is really tanked that intermittent fasting is an additional stressor that could drop them too low. Is that true? Yeah, completely. Yeah, absolutely. It's a big issue. Yeah, I actually did on my part. I did it did a dedicated podcast episode on have we taking fasting too far? Because I think really it has in a lot of people. Again, you know, there's a lot of advice we give with good intentions out on Instagram or Instagram. But for individuals, sometimes they'll take that advice in a way that could actually be, you know, a negative for their health. So, so the fasting movement, for example, this whole science of autophagy where, you know, we can cleanse and renew our body by creating new cells. I mean, it's very powerful, but you know what I'm realizing from seeing women in my practices, when they hear that concept that, boy, I can destroy my old body and renew my new body, that can really motivate them to like eat less and less and less and less. If anyone's got a borderline eating disorder, fasting can really push them over the edge. So I'm very kind of aware of that. So I have to counsel, I'm doing as much counseling with my patients about eating more than I am about eating less because now I've seen the pendulum sort of go in the other direction. And it's easy because if you're a workaholic in Silicon Valley, you can use intermittent fasting as an excuse to just to work more. I know why why should I eat when I can do all this stuff. So we got to be aware of those fine lines here. Oh, this is tremendous. So helpful. One of the things that we had, you mentioned in an email prior, and I love this question is heart disease and young people were seeing epidemic, especially since the pandemic. What's your thoughts or comments on that as it relates to metabolic? Boy, I know. So just to kind of level set here on some of the statistics and data. So heart disease has traditionally been the number one global killer and men and women. And for many years, especially from 1999 to 2011, we actually saw a nice drop in heart disease mortality. So death from heart disease. And this was obviously the non-smoking campaign, physical activity, some dietary changes, obviously medical interventions, statin medications, procedures were definitely much more successful. So we saw a drop, which is great news. But now as we kind of forward into the more recent decades, we're actually seeing heart disease death rates go up. And especially through the pandemic, we've been seeing an additional spike on top of that. And I've clearly been seeing this in my clinic. I often do do like coronary calcium scans, which can be a marker for early heart disease. And I'm starting to see a lot more positives in patients where I wouldn't really expect that to happen. And the age group that I'm most concerned about is we're seeing that spike in the age 45 to 64 year olds. So in that younger demographic, and actually the specific demographic that we've seen the greatest spike in mortality is in 45 to 64 year old women in particular. And so we've always, we've been through the movement of raising awareness around women's heart disease. But I still got to say that I don't think we're quite there yet. A lot of my women are still concerned about breast cancer, which it should be in other conditions, but heart disease isn't quite at the top of the list. And I think we have to pay attention even more now because now that we've seen that spike be dramatic. Now, what are the factors that are contributing? I have a couple of theories and concepts. Obviously, heart disease is very complex. But one thing that I saw in the beginning of the pandemic is when we were sort of in the midst of this chaos and people were sheltered at home, I did see that a significant percentage of my patients were actually walking more. They just needed to get out and hike. So when I monitored my patient's activity levels, a lot of their walking steps went up. But now the novelty of the pandemic is sort of worn off and people are just working like crazy from home. There's been a significant decrement and decline in walking steps. And I got to say, when I look at the step count data, especially based on a JAMA study from 2020, it is really direct in terms of death rates from cancer, overall death and heart disease. And the numbers we're looking at is when you typically get, the good side is if you're getting to 8 to 10,000 steps per day or more, that's when mortality rates are the lowest and they tend to flatten out. So you can get 12, 14,000, but it's going to be pretty flat at that point. The mortality rate really spikes when you start going below 7 or 6,000. That's when you really start to see heart disease and cancer rates and everything go up. And this has snuck up on people. And what I mean by that is in our post-pandemic world, where people are really not going to be office, how many incidental steps were we getting from parking in the garage and walking into the office? When we weren't getting all of our groceries and supplies delivered, how many steps were you taking when you go to Whole Foods or Cusk or wherever and you're walking from the parking lot and going down the aisles? That adds up to about two, three, 4,000 steps. So if you go down from 7 to like 4,000, dramatic increases in heart disease and death rates. And people, again, in some of my patients, I've even moderated their VO2 maths or metables and their fitness levels. That 5, 10, 15, 20% decrement is disastrous. And the older you get, the more that drops, heart disease rates do go up. So again, the diet and all the other layers have been there, as you know, for years. But I think this additional deconditioning has been a major factor that I think is contributing this. Of course, the stress factors are there as well too. But to me, that's been a real abrupt shift is that activity level. Gosh, I couldn't agree more because even personally, I mean, I go to the office and I've worked in, but there's a couple of days I do podcasts from home and every once, well, it'll be like four o'clock and I realize I've been sitting here doing interviews and I haven't even walked out my door and that's not like me. So it is like shock me. Okay. And then I'll be like, okay, I got to go on into a mile. Like walk tonight because, but it's really something to be aware of because we are sitting in front of screens a lot more than we used to. And like you said, before we'd go to the grocery store, we get delivered. All these things are really, they wonderful convenience, but it's not good for our heart. Yeah. And one thing I do want to say is what I'm teaching a lot of my patients and corporate clients is we have a bit of an all or nothing approach where it's like we're either sitting or standing like a statue or we're trying to hit an exercise or something, but there is an in between thing. And what I call that is like right now as I'm talking to you, I'm standing up a lot of times I've been Zoom meetings and I really teach people to be creative. Like sometimes I'm holding 30 pound dumbbells in each arm. I'm activating my core or I'm standing on one leg or I don't have to be on camera. So I can do a plank position or maybe I can do a walking meeting, but I tell people really the art and science of this is how do you weave physical activity and strength into your daily workday. So coming back to culture, you know, one of the things I talk about with my patients is, you know, rickshaw pullers in Asia, for example, their day job is pulling rickshaws. They don't have to go to, you know, 24 fitness or boot camp class because their work is doing that. So I'm really trying to get my patients. How do you make your job a little more physically active and if it's not designed to be physically active? Because that can make a huge difference. There are studies that show that people who even fidget more, like not a nervous fidgeting, but they're kind of, you know, their knee up and down and doing these things, you burn up to 1500 to 2000 calories. There's a disproportionate amount of chloride burn just for micro movements throughout the day. So that's something. And when people receive gems and they're just a little bit more active, they're pacing back and forth. Maybe sometimes you just shut the video off and just do a regular teleconference phone call because even this visual of seeing each other, that's not an actual thing throughout the day. You get a lot of visual. But I think some of those techniques can really help people integrate some movement and activity. And, you know, I think set in tourism also gets a little bit, you know, I tell people it's more stationary behavior because now people have stand-up workstations and they're like a statue. And really standing throughout the day just burns incrementally a little bit more than sitting. You can actually sit in a very active posture and actually burn more calories and standing stiff like a statue. But even shifting between sitting, standing and doing that. So I tell people avoid stationary behavior, not just sedentary behavior. So they know that even standings still may not be optimal for health too. Oh gosh, so practical. And I know people heard me on the podcast say this before. A couple years ago, I kind of stopped working out with those high intensity things. And I felt like I got much better shape. And my secret was I just like in my doorway here is a pull-up bar. So when I go through that door, I do a couple pull-ups. I love that. After my teeth brushing, I do a few push-ups. I just have these little things I sneak in. And I love it because in my mind, I'm not really working out but I am. But it's like, well, I'm waiting for coffee. I do calf raises. And so I have these little things I've just incorporated. And so they're these secret little mini workouts or like I'll do lunges when I was walking the dog before. Oh, that is awesome. Right? Just like what you're describing. But I love it because I don't ever go to the gym anymore. And again, back to Buteners' work on the Centagenarians, the commonality, they don't, none of them go to the gym. But they all move in their everyday life. Like that just go down the road to visit their friend or they are carrying hay bells to the cows. And I love that because we've gotten, so idea that we have to go to 24-hour fitness. And you've seen that meme of the 24-hour fitness, like going to the gym and riding the escalators to the stairs. Yes, totally public. And that was a really good point. So first thing is, I mean, I'm not discouraging people that have classes in the evening. I love classmates work. But the nice thing is when you're doing those incremental exercises, guess what? Your body's already warmed up. Your joints are lubricated. And you're going to get more out of that workout at six or seven p.m. And you're going to have a low risk of injury. When you're cold from standing or sitting all day, you hop in the car and you go to that class. I see a lot of injuries in my practice, sprained ankles, falls, all this stuff, just aches and pains. And the other thing exactly is when your workouts are too intense, I often see that incidental walking steps for the next 24 to 48 hours actually tank. So one key thing I want to say is excessive high intensity exercise. Number one has been shown to cause lower baseline physical activities if you're spending the next 48 hours recovering. The second thing is when exercise is really highly intense, coming back to energy partitioning, you're using a higher proportion and amount of glucose in the body. And that might be good if you're trying to keep glucose levels down. But the problem is, is you will actually consciously or subconsciously consume 15, 20, 20% plus more calories for the next 24 to 48 hours. And it's coming from carbohydrates. And I wish I could tell you that the body is matching it exactly to what you need. Overmatching, right? So I found too that if I'm doing a lot of high intensity, I get really hungry. I love carbohydrates just by doing this work. And it's dangerous for my exercise can really sabotage that. But when you hit that sweet spot, that moderate zone cardio, and yeah, once a week, you go after something high intensity is so much easier to manage the diet. Because then your body's not sending all these signals that I need carbs right now. So I'm glad you brought that up because that's the key. Some people are just overdosing on high intensity exercise, getting more injured. And these are actually some data showing that it might actually increase heart disease risk if you're doing too much of that high intensity exercise. Yeah, and really the cortisol, if you're really low, it's probably not the right thing. If you're really high, it might be raising it further. Yeah, you need that sweet spot for that for sure. You are such a wealth of information. What would be one takeaway if, you know, people listening to this, they may be dealing with pre diabetes or metabolic syndrome. Give us one kind of takeaway for the listener. Yeah, I mean, I think a lot of what we're seeing, you know, a lot of the prioritization, my clinic is sort of like, what should I prioritize first between diet and exercise? And when I first started my practice in my 30s and a lot of my patients around that age group, it's kind of magical that when you make dietary changes, I mean, you see immediate transformation. And I still see that. But when you get in your 40s and 50s, I find that the same dietary changes you might have made a couple of decades ago, doesn't quite get the same benefit. So I would say, especially beyond age 30, and for anybody, but really as we're starting to age, don't forget about physical activity, because I find people spend a lot of time micromanaging your diet. They're switching diets, they're adjusting their fasting window, should I do 100 grams of carb, should I do 75? I'm like, you know what, let just, you know, stick to sound dietary principles, you need to pivot to the physical activity. Coming back to the point about the step count and a lot of these things, I'm really concerned about how much aerobic deconditioning is happening. And one thing I want to leave people with is, as much as we focus on all these specific metrics, like blood pressure, glucose and LDL, still by far over the past few decades, we've seen one of the number one most important factors for heart disease risk is how fast you can walk or run a mile. So what I tell my patients is, when you walk in the evenings, I want you to have a circuit in the neighborhood or maybe at the local track and see how fast you can walk that circuit and write that number down, just like that's your LDL cholesterol, your glucose number. If you're exercising properly, not overdosing or underdosing, your one mile walk time should gradually get faster. And that is one of the strongest, strongest predictors of heart health and overall health going forward. And if you're medically motivated, just paying attention to that number is really, really super powerful. So I think I'd leave people with that physical activity message. I think we hammered away at the stress message quite a bit, but I can't leave without saying, do take stress seriously. Maybe the glucose sensor can motivate you more as well, too, but I think hopefully there will be some seeds. We planted pretty well through this discussion. Absolutely fantastic. I love it and I love on my walk. I'm going to start timing and see where I'm at my evening walk. Awesome. Great. So where can people find you, Dr. Ron, and your information that you think of the meta-program? I want to be sure and emphasize that and... Sure, sure. Yeah, so basically I've done quite a bit of writing on my blogs with culturalhealthsolutions.com. If you go there, you'll see there is a highlight for a program that I designed called the meta-program. And these are small group sessions that we do virtually where I teach people exactly what I do from day to night. We teach people how to exercise. We've got a WhatsApp group where people share how they're actually making changes in real time. So it takes a lot of these principles and turns them into daily practices. And then you'll get a lot of information there. My podcast is called the MetaHealth Podcast. And lastly, I do do some social media on Instagram. I usually post a couple of times a week scientific studies or show people some exercises. And my handle there is Ronner Sinha MD. Awesome. Everywhere you are listening to this in the show notes you'll find these links. I'll be sure and put them. Dr. Ron, it has been a pleasure to say hello, get to know you and your platform. And thank you for all the good you're putting into the world. Thank you so much for the opportunity. I feel a definitely kindred connection based on this discussion. We'll stay connected after. Take care. Absolutely. Thanks so much.