[MUSIC PLAYING] SPEAKER 1: Talks at Google
and the Asian Google Network are very excited to have Dr.
Ronesh Sinha with us today. He's an internal
medicine physician, and he's been pioneering
corporate wellness programs that help reverse chronic
health conditions like diabetes and cholesterol disorders
through targeted lifestyle changes. He's also the author of "The
South Asian Health Solution" and is committed to helping
improve people's lives, no matter what their background. RONESH SINHA: Thanks so much. It's such a pleasure to be here. I've been taking care of
Googlers for many years, so it's a pleasure to
actually come to Google and talk to you guys. So today, we're going to cover
a broad array of topics, really based on my work and
clinical experience in terms of how
I really approach my patients of
diverse backgrounds. You know, many of my patients
are of Asian background as well, and we're seeing a
lot of unique health conditions that I actually wasn't
trained to approach in medical training. There are a lot of different
nuances to the types of medical conditions we see. So we are definitely going to
be covering a lot of content. You're going to have a
lot of resource slides. Typically, people know
me in Silicon Valley for giving out a lot of
information during talks. So often, they do have to
watch replays of my talks a few times. But the nice thing about the
way we arrange this talk is we will have about 30 minutes
at the end for Q&A. I'm an adult physician,
so I take care of patients age 18 to 100-plus. But often, because of
my topic, I sometimes get questions regarding kids. So I brought my
wife, Shally Sinha, who's sitting there
in the corner. She's a pediatrician. So if there are any
questions about growth, micro-nutrients, or
a lot of the issues that we're facing
in kids, I'm going to have her back me
up on any questions like that because I
may not be equipped to answer all those questions. So with that, we'll get started. And I wanted to
sort of start off with a positive, empowering
message, because oftentimes, even in medical training, when
I was taught about conditions like type 2 diabetes,
we were never told that these conditions
can actually be reversible. So you're looking at a lab
panel of a patient up here. And this is a 52-year-old
software engineer who was diagnosed with
pre-diabetes back in 2003. He ended up developing
full-blown diabetes in 2014. And if you look up at
his labs, under 2014 you can see his glucose is 164. His triglycerides are high. And then there is also
number that I've circled called the A1C. And for those of
you that may not be familiar with that,
that actually tells you what your average sugars are
for the last three months. So typically when you're
A1C rises above 6 or 6.5, you've been diagnosed
with diabetes. So he ended up developing
full-blown diabetes. Incidentally, he had also seen
dietitians and specialists that had said that you're
diabetic now, so we need to start you on medication. So I saw him for a
consultation, and we went over sort of some
of my high principles. And we actually prescribed
some lifestyle changes. And literally in less
than three months, he went from 7.5 to 5.4. So you completely eradicated
diabetes in that visit. And this is really the types
of things that I'm seeing. And it's been overwhelming
to really realize that these conditions
that we didn't think were reversible can
actually be reversible. And I don't give false
hope to my patients, but what I tell them is we
are not a victim of our genes. Many of us have parents. We might have relatives that
have diabetes or heart disease. And when my patients
tell me, you know what, I might
as well enjoy life because I'm going to
become diabetic at 40, anyway, so let me eat these
Indian sweets or noodles or rice, but I told them, no. That's really not the case. Other patients sometimes have
a false sense of confidence because they tell me, my
parents lived to be 80. They were fine, so I can go
on doing what I need to do. But unfortunately,
they don't realize that some of their
lifestyle changes might cause diseases
to come on early. And so the way I want to
express that point is by using a concept called epigenetics. So quite simply,
what I tell people is think of your
genetic material as sitting inside a smartphone. OK, that smartphone
is inside your body. It's got all your
genetic material. And the way we used to
think about the genes were we thought
genes were hardware. You inherit this
gene, and that's what your programmed to
develop that condition. But the exciting thing
about epigenetics, we're finding that it's
more like software. So basically, you
might have inherited the app for type 2 diabetes
or the app for obesity, maybe the app for cancer
or Alzheimer's disease. But that app will not get
turned on in most cases if you implement the
right lifestyle changes. So what types of things
turn those apps on or off? Things like
emotions, which we'll talk about towards
the end of the talk. So stress, depression
can turn it on. Food and micronutrient
deficiencies, so eating the
wrong foods or when you're lacking the
right types of foods, that can turn the switch on. Inactivity, sleep deprivation,
and specific toxin exposures are all elements
that we think about. And if we can address
those topics the right way, you can become the first
person in the family not to become diabetic. So I think that's a very
empowering, hopeful concept, rather than this sort of genetic
what we call determinism, where your genes
determine your outcomes. And, really, when we think about
how those apps get turned on-- this is a very busy slide. But I'm just showing you there
are two root cause processes. One is called inflammation. The other is called
insulin resistance. And those are the
two root cause apps that lead to the development
of almost every chronic health condition out there, from
cancer, Alzheimer's, diabetes, all of that. And at a very high level,
I just want to go over. Inflammation basically,
at the most obvious level, is if I were to trip
here on these wires and I sprained my
ankle, you would see that my ankle
would become inflamed. It would become swollen,
red, and painful, and that's a
protective mechanism to prevent me from actually
moving that ankle in a way that would cause further injury. So that's actually
an adaptive response. But when inflammation is present
persistently at a low level-- so this is a level where
your immune system is active. OK, it's reactive, and it's
activated in a chronic fashion. That can lead to more issues,
like chronic health disorders. So that's inflammation
sort of gone haywire. The second process that I
put up on that first diagram is insulin resistance. And I want to spend some extra
time on insulin resistance because this really is
the root cause for most of the chronic health conditions
that I'm seeing in my clinic and that we're seeing worldwide. And I actually describe
insulin resistance as being a carbohydrate
parking problem. And this is an image and diagram
that literally in the clinic I show to every single
one of my patients. And I explain it to
them because once they understand this process,
then their lifestyle changes make a lot of sense. So let's spend a few
minutes and go through this. So think of carbohydrates. Carbohydrates are basically
chains of glucose molecules. Think of those as
being a car, OK? So this is basically
the carbs, our car, sitting in the
center of this slide. And you've got three major
parking lots in your body. You've got your muscle,
your liver, and your fat. The ideal parking
destination, the parking lot for those carbohydrates, is
we want that car to drive to the muscle parking lot. And the way the carbs get
inside that muscle parking lot is by using a special
parking pass called insulin. So when diabetics, for
example, have diabetes and they require
insulin, the insulin is actually the parking pass
that gets the glucose out of the bloodstream and into
the muscle parking lot. Now the problem is when we
become insulin resistant, that muscle parking lot is
not responding to the insulin signal. Our body is pouring out
more of the parking pass, but the muscle is
not responding. So maybe some of the carbs
are going to get inside, but now we've got all this
overflow glucose traffic. And where is that
glucose going to go? So the insulin parking
pass can usher the carbs into our fat parking lot. Unfortunately, unlike
the muscle parking lot, which has limited
space, especially if we're not physically
active, the fat parking lot is open 24/7. It's got plenty of
space, and that's why people can pile on
hundreds and hundreds of pounds of body fat. So that's one
direction it can go in. And that visceral fat we'll
talk about in a second, some of the side effects,
that belly fat. The other parking lot, it
goes through the liver. And the liver can take
those extra carbohydrates and either store them
and turn them into fat when they're in excess. So that's why there
is a condition called fatty liver, which we're
seeing a lot, especially in Asian kids and adults. That liver, when
it's overloaded, can also expel
those carbohydrates in a form of fat
called triglycerides. High triglycerides are a
major epidemic worldwide, and it's the most common
cholesterol disorder that I see here in Silicon
Valley amongst my patients. So we'll talk a little
bit more about that. But that's really
the root cause. It's basically, I tell people,
this is a parking problem. And we need to teach you how
to get that glucose car moving back towards muscle. We think of insulin resistance
as being linked to diabetes. Absolutely, root cause for
diabetes, heart disease, but now we're finding that
that same parking problem is being connected to all types
of other chronic health conditions. So one in particular that I'm
particularly concerned about is a condition called
Alzheimer's disease, which is a neurodegenerative
condition that can cause memory loss and
other cognitive changes. And the link between
insulin resistance and Alzheimer's disease
is now so direct. It's so intimate now
based on recent research that now they're calling
Alzheimer's type 3 diabetes. And one of the
reasons for that is because when you have
that parking problem and your body produces extra
insulin parking passes, those extra insulin
parking passes prevent your brain from getting
rid of a chemical called amyloid. And amyloid is
actually the substance that accumulates in the brains
of Alzheimer's patients. We also see that when people
have insulin resistance, a structure in the brain
called the hippocampus actually shrinks. And the hippocampus is
responsible for learning, memory, and
emotional regulation. So this is pretty
scary because we're seeing major increases in the
incidence of Alzheimer's all over the world. And it looks like
diabetes and insulin resistance is one of the
primary root causes for that. And that bullet point at
the end I'm showing you says that diabetics are
50% more likely to develop Alzheimer's disease. That's pretty frightening. And again, I'm not saying
that if you have diabetes, you're destined to
get Alzheimer's. Again, if you inherited
the app or the tendency, then diabetes is a major switch
that can flip that app on. Cancer, so again,
in my clinic, I deal a lot with diabetes
and heart disease. But we're also hearing
in our community about first-generation
cancers, a woman developing breast cancer even
though there's no family history of breast cancer. We're starting to see that. So again, a case of inheriting
an app, but then this condition might be flipping that app on. How this is connected
is number one. When you have
insulin resistance, your body can't dispose
of glucose properly. That extra glucose, just like
humans like to eat sugar, cancer cells like
to eat sugar, too. So cancer cells, their
preferred fuel is sugar. So if you're chronically walking
around with elevated sugar, and you have a tendency
towards cancer, then that could be a trigger. The second thing is,
again, I mentioned that when you have
insulin resistance your body produces
excess insulin. And that extra insulin
actually has secondary effects. So it can increase the release
of a substance called IGF-1, and that can accelerate
tumor growth as well. So we are seeing
that linkage there. And then finally, one other
condition I want to highlight is a condition called Polycystic
Ovarian Syndrome, or PCOS. And if you are a woman
or you have daughters, just be aware of this
condition, especially if you're of Asian or South
Asian background, where we see a lot of this. But basically,
this is a condition that's developing in
young teenage girls and in young women. And even when I was
growing up, I just realized that a lot
of our family friends, their daughters, reflecting
back, they probably did have PCOS. But there was no awareness
about that condition. And a young woman or a teenager,
the types of signs and symptoms they get off at that age are
things like irregular periods. You know, they can get acne. They can get facial
and body hair. But they can also lose hair
at the top of their head, and then obesity as well, too. So imagine for a second what a
teenage girl or a young woman goes through. Like, emotionally, having
these types of symptoms during certainly the
crucial stages of their life can cause tremendous
depression and other anxiety. But the downstream
impact of that is when you have this
condition as a young woman, your future risk of diabetes
is seven times greater, increased heart disease risk,
high risk of infertility, all these things. So I just want you
to be aware of this. And this is something to
address with your doctor if you start seeing that
some of these symptoms are starting to develop
in your daughter, or, if you're in your young
20s and have noticed some of these things because this
is a condition that's directly linked to insulin resistance. So when you think of
the human life cycle, a key thing to understand is
those two root cause processes, inflammation and
insulin resistance, those triggers can occur at
any stage of that life cycle. You know, as you're
an adult, you're parents, if you're having that
baby, in any of those stages those conditions can occur. And one thing I want to
actually highlight for you, too, is often I feel like
in some cultures, unfortunately, often
if a condition develops in the child, often the mom
is actually given the blame. You know, it's a very
sad, unfortunate thing, but that actually does
happen in cultures. You know, if there was
a behavioral disorder, if there's diabetes,
what happened during the mom's pregnancy? But again, coming
back to epigenetics, what I want to
make you understand is that now we have
lots of studies that show that the
male's lifestyle patterns before conception--
so if you have a male that's planning to get pregnant,
and they were sedentary, they're eating a poor diet,
they're not sleeping properly, they pass those on to the
gene pool through the sperm. So I tell my couples that
are planning to have kids, you treat that event-- if you're planning
to have children, that's the most important
event of your life. Treat it like an Olympic
event, and you train for it. Optimize sleep, stress. Eat the most nutritious
foods possible. Stay physically active
because otherwise, each of you are going to have a potentially
damaging effect on the gene pool, not only for offspring,
but also for grandchildren. So we see a lot of these
behaviors can skip generations. They can actually
come from grandparents and go two generations
down, so really this is an opportunity to influence
that gene pool as positively as we can. So which comes first? So even though I showed
them as separate processes, this slide just shows you
that insulin resistance and inflammation, they
feed on one another. When you've got diabetes
or insulin resistance, inflammation levels are higher. The extra glucose in the
insulin causes your body to be in a constant
state of inflammation. And also if you have an
underlying inflammatory condition, or if
you're eating foods that cause more
information, that will also put you at risk
for insulin resistance. So really it is a vicious cycle,
where one feeds upon the other. And I also want
to make the point about intermittent
versus chronic, because sometimes what happens
is you might read about some of this work. And you're like,
insulin's the enemy, or inflammation is the enemy. But I want to take
a couple of minutes to explain that it's not that
those entities are the enemy. It's basically intermittent
versus chronic. And what I mean by that is
intermittent insulin release is absolutely necessary
to control blood sugar. We need insulin to do that. Actually, intermittent
insulin release, when you use it the right way,
can help with muscle growth, too. So if you had a heavy
weightlifting workout, and then you had a good,
healthy carbohydrate that raised your insulin
levels, that insulin is going to take the protein and
carbs and send it your muscle. So your muscles can refuel,
and you can actually grow stronger muscle. So insulin can be
your best friend. But in the wrong context,
when it's persistently high, it can be your worst enemy. The same with inflammation,
the inflammation system was designed to protect
us, to heal us from injury, to prevent infection. But when it's chronic
and persistent, that's when the
devastation happens. With stress, same things,
emotional stress intermittently can build resilience. It can be adaptive. Physical stress intermittently
in the form of exercise is adaptive. On that note of
physical stress, I do want to say that in my clinic
and going around companies, often I see that people
are over working out. They're doing intensive
boot camps every single day, seven days a week. They're sore every day. And that's actually a chronic
stressor that eventually can lead to injuries,
or it can actually trigger more of that
blood-vessel-based inflammation. So many times, I'm
finding my execs in my clinic that are very
type A or other patients, I'm actually telling
them to slow down and maybe interrupt boot
camps with a bit more yoga, stretching, or just
outdoor walks and hiking. Calories, so
intermittent restriction of calories, a practice
that's popularly known as intermittent fasting,
can be incredibly adaptive. We'll talk about that. But obviously, the
persistent caloric exposure is really what's leading
to a lot of chronic health conditions. So let's talk about how we
can each assess our own health risk. OK, so biometrics, certain
lab results can be a guide. The great news I gave
you today is genes are more like software. So we can influence
and change our genes. And then we're going to
focus a little bit more on some key lifestyle
changes that have really helped my patients. So one of the key labs that
I want to talk about first are triglycerides. I mentioned to you
that that's probably one of the most common
risks that I end up seeing in my patient population. And I'm spending some
extra time on this because when I went
to medical school and we went through
medical training, when we looked at a
cholesterol panel, the number that we focused on
probably the most at some point was probably total cholesterol
and then the LDL cholesterol. But most of what I'm seeing
here and also globally, most of the conditions are
coming from the triglycerides. So let's understand
what triglycerides are. So that red tube that you
see at the top of the screen is your blood vessel, and that
yellow ball is a fat cell. So whenever we eat
foods, when the food goes from the bloodstream
and gets stored as fat, we call that process
lipogenesis, or fat storage. When our fat cells empty out
nutrients like triglycerides, when the fat cells
are broken down and that energy goes back
towards the bloodstream, we call that lipolysis. So in general, we
don't want to be in a constant lipogenic
state, because we're going to be accumulating
more body fat. We want to be able to make
sure that on a daily basis we're breaking down
body fat as well. So when people have
high triglycerides, that tells us that they're in
an excess state of lipogenesis. They're storing more
fat throughout the day. The other reason I
look at triglycerides as being important
is because they are an early marker of
insulin resistance, that carbohydrate traffic problem. So if you've had labs done, and
your blood glucose has always been good-- your
A1Cs are normal-- often patients are like, great. I don't have any signs
of risk for diabetes. But if your
triglycerides are high, I call that pre pre-diabetes. That's an early sign
already that your body has developed that
metabolic traffic problem, so be aware of that. High triglycerides
are an early trigger to atherosclerosis, which is
the process of plaque formation in the blood vessel walls. And it also leads
to the formation of a type of cholesterol
called type B LDL, and we'll talk about
that in the next slide. High triglycerides
also lower your HDL. Think of H as standing for
healthy, the good cholesterol. So typically, when you look
at a cholesterol panel, a very common pattern is you'll
see high triglycerides combined with low HDL. They go hand in hand because
the high triglycerides physiologically push
down the HDL levels. So really be aware of
those types of processes. LDL, one quick thing
on LDL, again, I mentioned to you
that it was really emphasized in medical training. It's still important,
but it's probably not the central culprit in
a lot of our patients that have insulin resistance. So think of LDL cholesterol
as being a cholesterol boat. So LDL carries cholesterol. The cargo is cholesterol,
and the boat is LDL. So basically, when you
get a standard cholesterol panel done, what
you're measuring is you're not measuring
the number of boats. You're measuring how much
cholesterol each of those LDL boats carries. When you get a more
advanced panel-- I'm not recommending
advanced panels in everyone. But really, what's causing a lot
of heart disease is two things. Number one, if you're generating
more of these small boats, we call those type
B LDL particles, and if there's a lot of them. So you can see in this
image from my book, there's a type B.
There's a boat that's anchored on to the side
of a blood vessel wall. When these boats attach
to our blood vessel wall, that's when they trigger
plaque formation, which can lead to heart attacks. So generally, when we have
more of the small boats, you would think that
big boats are worse, but it's actually the small
boats that cause more damage. More of the type B LDLs
is what causes damage. Now even without having to get
an advanced cholesterol panel, I'm going to give you a quick
shortcut for figuring out how you might have
those type-B boats. If your triglycerides
are typically above 150, it's almost guaranteed,
80%, 90% chance that you have the type-B boats. If they're above
200, 90%, 95% chance that you have type-B boats. So again, the main
point I'm telling you about this and the slide before
it is triglycerides, often that is the early marker that
instigates all these changes. It lowers the HDL, makes
you develop the type-B LDL. So if we can keep
track of that number and then make the right
lifestyle changes to reduce that, that's really empowering. You can see that you're
actually preventing a lot of these health
conditions from happening. So let's put some
numbers to this, OK? So this is a heart attack case
study, not an actual patient. The numbers are actual, but
I just put up a name, Ed. So Ed's a 32-year-old
VC, Venture Capitalist, who came to see me
after his first heart attack six months ago. He has a body mass index of 22. You know, so the general cut
off for the population is 25, but this guy's pretty lean,
based on his body mass index. He's got normal blood pressure,
non-smoker, exercises five days a week. And he was told that his
lipids are not highly concerning by his last doctor. So now let's go through
his numbers, OK? So I put the target
levels on the right column and his results
basically in the middle. So the first thing is his
total cholesterol is 190. And I actually put target
level as not important because usually what does it
say in most cholesterol panels? What number is the one
that triggers concern? When it's above
what, 200, right? Whenever people have a
cholesterol above 200, then they get concerned. But in this case,
his is less than 200. So most people would say, hey. That's not too bad. His LDL, that bad
cholesterol, is 108. So typically, a cutoff might be
less than 100 or less than 130. So that's really not that bad. His HDL came back at 32. That's the healthy,
good cholesterol. And in males, we want
that to be above 40, so that's kind of
low in his case. The triglycerides
came back at 250. And the cutoff for
most labs is 150. But I'll tell you, based
on more recent science, we want that number
to be closer than 100. There are actually some
health care entities out there that use the cutoff of 400
or 500, which is astounding. We've got to make sure
that it's less than 150. 100 or below is even better,
so his was clearly high. And then I put it
in red, the ratios. So this is a key point. When you look at your
cholesterol panel, pay attention to ratios
rather than absolute numbers. The first number is the total
cholesterol to HDL ratio. You take the 190. Divide by the
healthy cholesterol. The ratio is 5.9. So it should be less than 4.0,
so that ratio is elevated. The other number I
want to tell you about is not reported on nearly
all cholesterol panels, but I think is one of the
most important ratios you can understand, the
triglyceride to HDL ratio. You take the triglycerides. You divide by the HDL. The ratio should
be less than 3.0. His ratio came back at 7.8. So if we had looked at these
ratios in the right way, if I had seen this
guy 5, 10 years ago, I would have been all over him. I would be like, we have to
make sure we fix this as soon as possible, because his
high-stress lifestyle, even though he's
exercising, he's young, this sort of cholesterol
panel with high stress, probably some family history-- I can't recall, probably
had some family history-- this led to the development
of very early onset heart disease, which we're
seeing very commonly. So when we're talking
about body fat, too, so body fat ends up being
a major risk as well, too. So I want to spend a
few moments to explain to you about body fat. When you think of body fat,
let's use a jelly donut. I know this is not the most
nutritionally sound analogy. This my trigger some
hunger in people, but I don't want to use this
as an example of body fat and the two major
types of body fat. So think of the jelly inside
as being a type of fat called visceral fat. We also refer to that as
being like an inflammatory fat because that's the
type of fat usually around our belly
and waistline that causes chemical
substances to be released that can trigger inflammation. Now the crust of that
jelly donut, think of that as being subcutaneous body fat. And subcutaneous
means under the skin. So most of the visible, external
fat that we carry around, that's hanging
over our belt line, is subcutaneous fat,
where the deeper fat that sits inside our liver or
encases our internal organs, that's the visceral fat. So even though the
external, visible fat might seem like
it's more damaging, it's that more invisible fat
that causes more trouble. Now I'm putting up this diagram
of different ethnic backgrounds because the distribution
of jelly to crust varies based on your
ethnic background. You look at Caucasians, and
their distribution of jelly to crust, moderate jelly. And they've got a fair
amount of crust around that. African Americans,
interestingly, relatively, have a smaller amount of
that inflammatory jelly, but they've got more of
the visible, external fat, the subcutaneous fat. And it's interesting. So African Americans do
develop diabetes as well, too. Their incidence is not
as high as most Asians. A lot of their heart disease
comes from hypertension. Their rates of
high blood pressure are much higher than
the other ethnic groups. But then look at the
Asians on the right. Asians on the right,
relatively speaking, are carrying around a
lot more of the jelly, more of the visceral,
inflammatory fat. But they've got a very thin
rim of the visible fat. And the reason I see so many
Asians with heart disease at a normal body mass index is
because of that distribution. They've got more of that
deep, invisible fat, but they've got less
of the external fat. So often, many of my
heart attack patients have normal body mass
index, or they're skinny. They're, like,
pencil-thin skinny with very skinny arms and legs. And they're shocked that they
develop diabetes or develop their first heart event. It's because they're carrying
more of that jelly, so really important to keep in mind. This is a slide of two famous
obesity researchers, Dr. Yajnik and Dr. Yudkin. So Dr. Yudkin is on your left,
and he's basically from the UK. And Dr. Yajnik is
from South India. And I'm just putting
up this slide. They've done a lot of
compelling research around insulin resistance. And I'm just putting this
slide up to show you. They're actually at
an Indian wedding. You can see by the saris
in the background there. And they actually have an
identical body mass index. But then look at their scans. So what you're looking
at on the sides here, those are DEXA scans. So DEXA scans are basically
used traditionally to measure bone density,
but they're also very accurate imaging
studies to look at fat. So the dark-purple
areas are fat. So you can see
that if you compare the skinny guy on
the right here, he's got significantly more body
fat than the doctor on the left there. And you can see the body fat
comes down to be 9% versus 21%. So clearly, he's not
carrying around much crust, right, not much
subcutaneous fat. But he's storing a
lot of visceral fat. So very, very high risk of
heart disease on the right. And this is a cultural
thing, you know. In my book, I kind of
joke about the fact that a lot of times if you've
got a son or a son-in-law like this, what does
the family want to do? They want to overfeed
the heck out of that guy because they think that
he's going to basically starve to death, right? And a lot of times, skinny
guys, a lot of my skinny Asians, think that they got
the lucky genes. So they go around, eating
whatever the heck they want. And they don't realize
that they are actually causing a bad problem, making it
worse, because they're actually causing more inflammation by
storing more fat in the liver. Often, these slender
folks have fatty livers. We check their liver function
tests and ultrasound. And their liver is stocked
away with all this storage fat. And that's why a key
message is really don't judge anybody
just by looking at them. I have plenty of people
with high body mass indexes. And their heart
disease risk is quite low because of the
lifestyle that they lead. Their numbers are good. But plenty of slender
folks that are not leading the right lifestyle,
and their risk of heart disease is significantly higher. And one other thing I
want to mention, too, about the problem with
the guy on the right is not just the visceral
fat that he's storing. There's something else
that really concerned me. It's the fact that he's so
skinny in his arms and legs. When you're that skinny,
remember my parking diagram. We want our muscle parking
lots to be vigorous and strong. When you've got
stronger muscles, they store more carbohydrates. When you've got skinny, skinny
arms and legs and you're not working out at
all, what that means is it takes less carbohydrates
for you to start shifting traffic into the liver to
make triglycerides and fat or into that visceral fat store. So it's a combination-- more of
that fat causing inflammation and less storage space, less
energy demand from the muscles. And we have to attack
both of those problems if we want to really
reverse this risk. So based on this, so waistline
targets based on ethnicity are actually
stratified because of that jelly-to-crust difference
between different cultures. This is up here
for your reference. So the waistline
cutoffs for US, somebody from European background, or
somebody from Asian background is different. So unfortunately, somebody
from my background, I've got less room for
error around my waist. So I've got to stay leaner
than somebody that's from a different background. Now these are
general guidelines. I've definitely seen a
lot of slender people of European descent that still
have a lot of visceral fat, and they have fatty liver. But culturally speaking,
because of that tendency, you have to look at
culturally tailored cutoffs. And this is something I'm
educating the medical community about because often
you'll see a doctor. And you get treated
like everyone is from the same
ethnic background. We're looking at the same
body mass index scale, the same waist circumference. But we've got to really
culturally stratify that information. Waist-to-hip ratio is
another very powerful way that you can assess risk. So basically, when you
look at different cultures, body mass index doesn't
tend to work very well. It's a very blunt tool. So body mass index,
again, is your weight relative to your height. But waist to hip ratios
are a really accurate tool for assessing
heart disease risk. So you take your
waist circumference. You divide it by your
hip circumference, and you get that ratio. And I've got some videos
and other references that show you how to do this. Look up a video that
says how to measure the waist-hip ratio accurately. But I've put the cutoff there. So this could be
a much better way to assess risk because we're
really trying to assess that dangerous visceral fat. There's actually a
gender disparity, too, in fat distribution. I want to go over this briefly. So coming back to buy,
my carbohydrate car and that jelly donut diagram,
interestingly, women, especially before menopause,
more of their carbohydrates tend to go to the crust,
more of that visible fat. For guys, interestingly,
their glucose traffic tends to go to the jelly. OK, so what does that mean? So I see a lot of
couples in my practice. And often what happens
is you'll see the guy. He's, like, 20, 30 pounds
maybe lighter than the wife, but his triglycerides
are through the roof. Inflammation levels are high. And the reason is
because his traffic is going towards the visceral fat. And his traffic's also
going to the liver to produce triglycerides. The woman, you know,
is like, my God. I'm, like, 20, 30
pounds heavier. All my numbers are normal. But why am I still
storing that extra fat? Because more of her fat is
going to the subcutaneous layer. Less of it's going to the liver. So before menopause,
why does that happen? I mean, when you
think evolutionarily, women were designed
to protectively store more fat because it's
to basically promote progeny. OK, in times of
stress and things, women are supposed to store more
fat in that subcutaneous area. So they have more of a
protective filter that prevents the
cholesterol from going in the wrong
direction, the carbs from going in the
wrong direction. But unfortunately, when they hit
perimenopause after menopause, things change. So now all of a sudden,
we've got more traffic going towards that
inflammatory fat. In many of my women,
when they hit 45 or 50, we start seeing fatty
liver triglycerides go up. So I tell women, don't
feel bulletproof by this, especially if you
have a family history. You've got to
prepare for the fact that maybe towards menopause
or after menopause, these numbers might start to
go in the wrong direction. So we've got to
really prevent that by being proactive early on. So this might be a
reason why we see this. That subcutaneous fat,
it's a separate topic. It's a little bit more
difficult to shed. So when we see couples
that go on lifestyle plans, typically the male will
shed their fat very quickly. But subcutaneous fat, we'll
talk about this actually in a couple of future slides. There are other elements
to subcutaneous fat that makes it more
difficult to shed than just exercising
harder and just reducing carbs or calories in the diet. So how do you tell that you
have that insulin-resistant carbohydrate traffic problem? So I put a list of criteria. Most of these overlap
with a condition called metabolic syndrome. So if you looked up metabolic
syndrome, a lot of these are similar. But, again, we've gone over
most of these principles, so these should make sense. The increased waist
circumference or visceral fat, the high triglycerides, the
low HDL, the blood glucose, which can be
represented by a glucose level or an A1C,
high blood pressure also is linked to
insulin resistance. If you have certain
specific conditions, like gout, like fatty
liver, or like PCOS, acanthosis nigricans is
actually a hyper-pigmented skin disorder. So a lot of people of South
Asian descent, for example, might have these dark
streaks in their skin folds. That's actually a sign
of insulin resistance. And then diabetes
during pregnancy or gestational diabetes are
all obviously associated. Now high-risk ethnic groups,
South Asians, East Asians, we're seeing it. Hispanics, Latinos, Filipinos
tend to relatively have more of these issues. Native Americans
have very high rates of insulin resistance as well. So these ethnic backgrounds
do put us at greater risk. So how do we overcome
insulin resistance? At a high level, I'm putting
this traffic diagram. This is a bit of a
different image from this. And we're going
to dig into these in a little bit more detail. But I want to talk
about a few concepts based on these
different parking lots. So the first thing is when
we look at our muscle, we talked about
this a little bit. But the first thing is
we just have to reduce the carbohydrate traffic. If we're eating excessive
amounts of carbohydrates on a daily basis, our muscle
parking lot is constantly full. And what people don't realize
is if they go through a day, and they overate
carbohydrates, I wish when you wake
up in the morning it would just automatically
reset and just clear the cache. The memory is gone, and
the muscles open up. It doesn't happen. Your body stays
closed the minute you wake up in the morning. So even the healthiest
carbohydrates you take in, they have no physical
space to get inside. So we do have to
regularly make sure we're keeping track of that
carbohydrate traffic and keeping it on the lower end. We want to do some form
of resistance and strength training. So if you're only doing
walking and cardio, those are great for your health. But again, if you're
a slender Asian that doesn't have much
parking space, we might have to up the weights a
little bit and do some squats and focus on the
larger muscle groups so we can enhance
the parking space. We want to increase overall
activity, getting more walking steps, doing all those things. So that's the muscle end of it. For the liver, same concept. We want to reduce that glucose
traffic because your liver actually take starches, right? So why do I see so
much high triglycerides in my vegetarian Indians
who don't eat red meat, and they hardly eat fat? Because the main fuel
for their triglycerides is coming from the starches. It's coming from the
flatbreads and the rice, even the lentils in abundance. So we have to reduce
that carb traffic. We also want to eat clean
foods because our liver is our filter that detoxifies. So if you're eating foods that
are processed and packaged, if you're eating out a lot
and using inflammatory oils, that's going to
clog up the liver. If you're drinking
alcohol excessively, that's going to prevent us
from cleansing the liver. And then practices like
intermittent fasting will help empty out some of the
extra glucose and fat stores. Now it's a longer list
on the right side. Some of this is similar. Reducing carb traffic,
eating cleaner foods, intermittent fasting, powerful,
managing stress and sleep is a huge part. A lot of this subcutaneous
fat, believe it or not, is really linked
to our emotions. And unless we're able
to manage emotions, that subcutaneous fat
holds on because, again, for a woman's body
in particular, that feels like a threat. You're in a threatening
environment. I'm not going to shed
this fat because I'm going to pop out a baby, all right? Even if you're not
planning to have a baby, your body is thinking
like that all the time. That's like a comforting,
insulating type of fat. Replenishing
micronutrients, so even if you're on a low
calorie, low carb diet, if there are specific
micronutrients that are missing, then that might
promote excessive fat storage. Restoring hormonal balance,
so in addition to insulin that we've talked
about, melatonin, because of disrupted
sleep patterns, cortisol, which is
our stress hormone, if we don't fix those things,
we may not shed that fat. And then we do want to limit
any environmental toxins we might be exposed to. And then just a quick point, so
I'm all about root cause, OK? So now you guys know the
metabolic nutritional underpinnings of why
insulin resistance happens. But there's a lot of behavioral
psychological underpinnings, too. So I often tell people that
insulin resistance, at its root cause, often comes
from inner resistance. Many of us are going to
walk out of this talk. We're going to understand
what we need to do, but we're still not
going to do it, right? So what are some of the reasons? I don't have time right
now, but, you know, things will get
easier later in life. We all know that life
does not get easier. I'll wait till the
kids get older. My wife and I have twins. So when they were babies,
we were like, gosh, once they hit 8, 10, whatever,
things will get easier. Things are not easier, right? You just find a different way
to become overwhelmed and busy. Once my startup, I
see a lot of execs, or I see a lot of people
working in companies. And they've got
business ambitions. Once this startup or
this idea takes off, then I'll have more time
to focus on my health. I'll have money to hire a
personal trainer, whatever. We've talked about genes. Diabetes is in my family. I can't escape it. Why bother? Well, today I've
told you, definitely bother, because you can
be the one to not have diabetes in the family. And then we talked about
the other part of the genes, where people are like, well,
my parents lived a long life. I'm protected. Don't think like that. And then the last one,
which is my favorite, I hear all the time. Eating lots of rice
is part of my culture. I can't avoid it. I'm predestined to eat that. And I want to use that
last point to transition to my next slide,
which basically is if you are going to say
that, well, I want to eat rice like my ancestors, then
you have to start living life like your ancestors, too. You can't be selective about it. I'm from a part of
India, from Calcutta. So I'm Bengali. When I was growing
up, every summer, we'd go out to Calcutta, and I'd
marvel at the rickshaw pullers. We lived in an area that
was right near the rickshaw pullers, and I would
always watch these guys. And the thing with
rickshaw pullers-- I actually found
this while doing a little bit of
research-- is on average, they run about
40,000 steps a day. And they're doing it in
a sprint type fashion. They sprint, stop, sprint, stop. So they're literally
doing interval training for several hours each day. They have definitely
got strong legs and core because they're carting
around families, where they're becoming heavier and heavier
because of the obesity crisis, or other loads as well. So they've definitely got
a strong leg and core. Normal vitamin D
levels because you get most of your vitamin
D from sun exposure. So if you're dressed
like that and you're out in the sun all day,
you're not going to have vitamin D deficiency. And vitamin D is not just
about bone health and strength. The vitamin D actually
helps lower inflammation. It can also help with
insulin resistance. That metabolic
traffic problem, when you're vitamin D
deficient, there are studies that
link severe vitamin D deficiency to worsening
insulin resistance. So for this sort of guy,
eating extra servings of rice is OK, all right? But what about my
guy on the right? 2,000 steps is on average what
my engineers tend to walk, 2,000 to 3,000 steps. I actually track their
steps like a vital sign. So this guy is
about 20 times less active than the guy on the
left, weak leg and core from sitting all day,
rampant vitamin D deficiency because we've replaced
sunlight with screen light. For him, lots of rice can
cause a completely different metabolic disturbance, insulin
resistance and all these health crises. Now I'm not saying we
have to quit our jobs and become rickshaw pullers,
pulling rickshaws down the 101. But we do want to mimic some
of these lifestyle habits however we can. And doing some of this
can make dramatic impacts on a lot of the
health conditions that we've talked about. So again, coming back
to the whole issue of the metabolic
traffic problem, this is a little slide
image from my book. But these are the types of meals
that I see in the patients that come into my clinic. So typically, instead of
looking in calories and fat, I will get people to understand
how many carbohydrates or net carbohydrates should
they be consuming each day. And by net carbohydrates,
what that means is you take the grams
of carbs in a food. And you subtract
the grams of fiber because that's the
healthy part of it and see how much
you're left with. You can use an app, you know,
MyFitnessPal or some sort of fitness tracker. And just see on a daily basis
how much you're consuming. So you can see. This is a relatively benign
looking meal, very common. This woman, Sumita,
is eating one chapati. She's having a cup of cooked
lentils, a cup of cooked-- aloo sabji is basically
a potato-based curry. So that's one meal. And in that one
meal, she's basically consuming about 94 grams
of net carbohydrates, which is about what I eat
in an entire day. So that's where the problem is. Even though this is
low calorie, low fat, she's eating this two
to three times a day. That's going to lead to more
of that carbohydrate traffic problem. What's happening in China? We're seeing a major
epidemic of diabetes. The rise there is incredible. I found this one meta analysis,
which looked at several studies to assess how much rice is
being consumed in China. 625 grams of rice daily, right? And I just told you,
probably an optimal for our modern lifestyle
is between 100 to 150. That's about four
servings daily. When they compare that
to Western populations, they do about two to three
servings of rice per week. And this is just rice. This is 625 grams
just from rice. And on the noodles, the
desserts, whatever sauces, and the carbohydrates, we
might be close to 1,000, right? So that's really what's really
causing a lot of the issues that we're seeing
throughout Asia. So based on what I told
you, many of my patients-- so the thing that was
really startling is I found that I was seeing so
much heart disease and diabetes risk in my vegetarian Indians,
for example, my vegetarian patients. And I'm definitely
a fan of eating more of a plant-based diet. But we have to make
sure that we're actually eating plants along with that. Most of my vegetarians are what
I call grainatarians, right? So this is, like, a type of
meal that my uncle in Calcutta would eat. And I just wanted to show you. You can see we've
got two flatbreads. We've got a bowl of rice. Those four brown golf balls
are Indian sweets there. You know, there's all
these other carbs here. And the interesting thing is he
would eat through this plate, and the tomatoes and cucumbers
would always be left behind. So I always tell people,
that salad, actually, it's not meant to be eaten. It actually has a
decorative purpose. It just adds color
to your plate. But eating it is
optional, right? So this is a type of vegetarian
meal that we're eating. And even in Asian noodle dishes,
we might have some vegetables. But there's a lot of
starches, and often they're cooked in the wrong
types of oils. So those processes of
inflammation and insulin resistance are really
propagated by eating foods like this on a regular basis
and not being active, not creating that muscle demand. Carb copycats is one concept
I talk about in my clinic. How do we eat foods? Now I'm so happy. When I first wrote the book, I
put the recipe for cauli rice in there. I was telling people, try
to lower your starches and add these carb
copycats into your food. And now as you know,
most grocery stores, Trader Joe's, have cauliflower
rice pre-riced for you. But these simple
substitutions significantly bring down our net carb intake. That lowers insulin. It causes your body
to burn more fat. So this is just a game-changing
tool that can really help lower visceral fat. So simple changes
like this are really encouraged in all patients. Now I get a lot of questions
about saturated fat. Is it good or bad, right? I mean, it depends on the week. Every week, I feel like
the news headlines change. Saturated fat is good for you. No, saturated fat
is bad for you. And really, it depends
on the individual person. It depends on your genes. So I put a couple of names
of different genes out there. But basically, in my patients,
I don't check these genes. But what we do is if we put
them on a diet that's lower carb and maybe a little bit
more saturated fat, I'll check their cholesterol
in two or three months and see how the numbers look. In most cases, if they're
eating healthy sources of saturated fat, I don't see
adverse cholesterol elevations. But in some cases, if
these genes might be off, there might be significant
elevations in cholesterol. And then we have to reassess. Are we eating too much ghee
or coconut oil or butter in the diet? So my overall approach to
fat is you want to diversify. Right now, coconut oil
is all over the news. Everyone is putting coconut oil
in their hair, in their mouth. Whatever they can find,
they're putting coconut oil. And I'm not opposed to that. But I tell people, you want
to diversify your fat intake because although
in many patients I find coconut oil
and butter and ghee will not raise
their cholesterol, they have not also been found
to be as heart protective as some of the other fats
that have been around or have been
studied more deeply. So emphasize the evidence-based,
heart-healthy fats, the monounsaturated fats like
olive oil, avocados, nuts, and seeds, omega 3s from
marine sources or leafy greens. Eliminate the
hydrogenated trans fats. Hopefully, we were
doing that already. Cut back or cut out
the seed-based omega 6 oils like safflower,
corn, sunflower. Many of us are still
cooking with these. But these are highly
processed oils that can trigger
inflammation, especially if you cook at a high
temperature with them. And then if you're using
some saturated fat, make sure they're well-sourced. And use them in
moderation, especially if you've seen any elevations
in your cholesterol. So if you diversify
that fat intake, you should be in
good shape, rather than focusing on just one
type of saturated fat. So overall approach,
whether you're vegetarian or non-vegetarian,
half that plate has got to be vegetables, OK? A lot of people
on low-carb diets use that as an excuse
to eat a lot of meat. That's definitely not
a healthy approach. Half of it's got to be veggies. We've got a corner of protein,
a corner of carbohydrates, some of the healthy
fats, there, too. And then I vary this in
myself and my patients based on activity. If I did a major endurance event
or did some really hardcore workout for an hour,
then I can starch up because my muscles
need that starch. If I had a day where I
sat in meetings all day, and my muscles don't
have much of a demand, I'm going to be much
more restrictive about the carbohydrate intake. Same with the protein,
if I did heavy lifting, and I've broken
down some muscle, and I need to rebuild
some new muscle, I might amp the protein up. But if you're just sitting all
day and eating lots and lots of protein, that's
not good for your body at all because excessive protein
intake when you're sedentary will cause the release
of that chemical we talked about
earlier called IGF-1. And that in high amounts
on a persistent level can cause more tumor
cell proliferation. It can actually
increase cancer growth. I put a list because
I always get questions about proteins and vegetarians. And I think there was
already a question on Dory. I put the list of some of the
vegetarian proteins there. And I did a dedicated
protein post on that, so for vegetarians. Sp clearly, vegetarians can
get multiple healthy protein sources into their diet. OK, so exercise, I think we're
all aware of activity monitors. We want to make sure we're
getting regular steps because prolonged sitting does
cause an elevation in glucose and triglycerides. So try to interrupt prolonged
sitting every 20 to 30 minutes. Use these trackers to
keep you motivated. I tell people, make sure you've
gotten at least 4,000 steps by 12:00 to 1:00 PM so you're
distributing your steps throughout the day. Interval training is a great
way to clear parking space. If I overate carbs one
day, my goal the next day is, how do I make parking space? Interval training is a quick,
efficient way to do that. So you can use apps
like Tabata or Seconds, but basically doing anything
high intensity for, say, 20, 30 seconds and then
pausing for 15 seconds, 20 seconds again. Do a few sets of that. In 10 to 15 minutes, you can
clear a lot of parking space in the muscles. So these are great ways that
you can trigger fat burning, boost growth hormone. But the one thing I
tell you is people that do short-session
HIT training, sometimes they use that as an
excuse to actually sit longer. They'll do a 10
minute workout, then they go straight back
to their computer. No, don't do that. I mean, you definitely
want to still incorporate some longer exercise
sessions to allow your body to really benefit from that. So don't just substitute an hour
workout with a 10-minute HIT session. And then resistance
training, so this is in India during the monsoon season. It's hard enough that these
guys have to pull humans. But then all of a sudden,
they have to pull them through floodwater conditions. But resistance training,
like we've talked about, is another core part of really
reversing insulin resistance. So do full-body-type workouts. Use your legs. Do squats. Do lunges. I tell my patients,
when you go to the gym, when your motivation
levels are highest, that's when you want to do legs. If you wait till after the
aerobic and the other weights to do legs, often people
don't do them properly. And really keep in mind
that leg power actually does help brain health. So this study was done
on identical twins, where they actually looked at what
was the strongest lifestyle predictor of reduced brain
degeneration or loss in memory. And they found
that leg power was the actual number-one factor. So believe it or
not, leg strength does actually contribute
to brain strength as well. These are some apps that
I've used in patients to really motivate them
to exercise and use their total body, so doing
things like plank and squats. You can use these apps
to actually track it. So sometimes, I'll have
my patients come back and report back to me. How many squats are they doing? What's their plank time? So there are some great
tools and devices out there to really encourage
full-body workouts. And then I tell people, create
your own rickshaw, right? So one big concept is
this rickshaw puller, he's not doing it
because he's trying to reverse insulin resistance
or lower inflammation. He's doing it out
of his livelihood. And that's the same thing
we have to sometimes do. Can you create an active
workspace in some way? So I wrote more than half my
book on an elliptical machine. I would spend two to three hours
on that elliptical machine, just typing away. So I wasn't thinking,
oh, my gosh. I'm burning fat. I was actually doing
work while doing that. Now there are some types of
work where I can't be in motion. I've got to be seated and still. But sometimes, you're
going through your emails. You're going through your
iPad messages, whatever. You might be able to
do it on your bike or maybe on a walking treadmill. We've got to make activity
sort of part of our work life, otherwise it's very
difficult to stay ahead of these chronic
health conditions. And then in terms
of burning fat, keep in mind that just
intensifying exercise isn't necessarily the way. What are we eating
before we exercise? So fasting workouts work
really well in many people. So this particular
study looked at some of the genes that were
actually turned on when you exercise in a fasted state. So fasted means
you still hydrate. You maybe have
your tea or coffee. But they found on the right
side that basically those genes, PDK 4, HSL, these genes
were actually switched on. So there was more
fat burning happening in people that didn't eat
anything before breakfast versus people that had their
healthy pre-workout breakfast. So keep that in mind. OK, so now that you're an
expert on these numbers, I want to show you my own data. The reason I'm
passionate about this is because despite me following
a lot of the standard health guidelines, I actually developed
pre-diabetes and metabolic syndrome. Now that you guys are
experts on these numbers, you guys can analyze my numbers. You can see back in 2009, my
triglycerides at that point were 314. My healthy cholesterol was 28. Look at my total cholesterol. It was 154. So most people would
look at that and go, wow. Your total cholesterol is great. But now you know that that
really doesn't give us much valuable information. Look at my LDL cholesterol. That was 85. That looks really good based
on most of the cutoffs. But the issue here
was look at my ratio. The triglyceride to HDL
ratio came in at 11.2. Does anybody remember
what the cutoff is? It should be less than-- sorry? AUDIENCE: Five. RONESH SINHA: It's actually
less than 3.0 is the cutoff. So I was well above that. And why was my LDL
so normal-looking? Because I had those type B. So I knew about this already. So I checked my size pattern. I had type B. When
you have small boats, small boats carry
less cholesterol, and that can make
your LDL look lower. So it's really false. It's kind of like a false
number because it's really representing smaller particles. As I made dietary changes and
I dropped the triglycerides over the years, you can see that
my healthy cholesterol went up, because those are
intimately related. My LDL actually went up but
in a good way because look. I went from type
B to type A. Now I've got the larger boats that
don't cause as much damage. They carry more cholesterol. So in a cholesterol
panel, the LDL is going to be a
little bit higher. But look what my ratio
is now, right, 1.9, 1.6. So that's where the power
of lifestyle changes. You can see one of the
critical foods that caused my damage
was steel-cut oats and a banana in the morning. That comes out to be about
47 grams of net carb. And I know, based on
my labs, that when I go above 100 on a sedentary
day, my triglycerides go up. So switching to an omelet,
or for my vegetarians I might do more of
a yogurt-based meal with nuts and seeds, we
dropped that number down. All of these numbers
get reversed, all without medications. That's really our goal. And then for
inflammation, I just wanted to put this
up and just show you. Just ignore the other numbers. But this CRP is a test
marker for inflammation. It's not necessary
in all patients, but I want to show that this
guy's inflammation levels were quite high. And then with lifestyle changes,
he dropped it initially to 3.6. It was still stuck there. But then we dropped it to 0.6. So what was the single change
he made that dropped it from 3.6 to 0.6? It was meditation. So I want to make the point that
chronic persistent stress does activate the immune system
and cause more inflammation. So this guy, purely through
meditation and mindfulness, was able to actually
lower that number. So I always remind myself
about this example. And really it actually
has encouraged me to add more mindfulness
practices as well. So, please, do be aware of that. And based on stress, I kind
of call this condition chronic entrepreneur's syndrome,
where we have a lot of people, I see a lot of execs
that are very successful. They're lab numbers
are completely normal. They're very fit, but
their stress levels are high all the time. And it feels normal because
they're always hyperactive. They're sleep
deprived, and they're coming in with their
first heart attack, despite having normal labs. And as I've seen more and more
of these patients in my clinic, it's motivated me to actually
really take that lifestyle balance more seriously. Every single person in this
room is an entrepreneur. If you're thinking about
doing something greater than yourself, your
mind is active. I'm not saying
that's a bad thing. But if we're not doing
mindfulness practices to break up those
active situations, then we might be putting
our health at risk. For women, we've talked about
some of the issues in women. So obviously, the
more common issues are hormonal compromise,
infertility, PCOS, resistant weight loss,
mental health disorders, a lot of autoimmunity, so
Hashimoto's thyroiditis, which is a root cause for
an underactive thyroid. Post-menopausal, we talked
about heart attack risk approaching males. I talk about this a lot. But the key high
level point I want to make for women's health
is usually emotional obesity is more common
than metabolic obesity. So many women that
come to see me, they already have
a personal trainer. They're working out
five days a week. They've tried every diet
and cleanse under the sun, but they've refused
to manage their stress and improve their sleep. Often, they have to do more
yoga instead of boot camps and walk more or
spend time in nature before they see those
stress hormones normalize. And then that
subcutaneous stubborn crust fat starts to shed. OK, so keep that in mind. Often, micronutrient
deficiencies, so if you're eating the
same foods all the time, and you're not adding
the right micronutrients, that can promote more
of the fat storage. And so, again, key point is
just adding more exercise and cutting calories
back may actually make that problem worse. So self-acceptance is
critical for, really, emotional and
physical well-being. So really try to
incorporate those if you've tried everything else. I know we're already
at an hour, but I just want to make a quick few
other closing points just on how we prevent insulin
resistance in our kids, because we are seeing this
condition happening in children at a very early age. This lifecycle just shows you
how an unhealthy pregnancy-- when people are
insulin resistant, so in some parts of the
Bay Area, in Fremont, I talked to a doctor
who said they're seeing Indians that have
about a 50% incidence of gestational diabetes. About half of the Indians
who walk into the clinic have diabetes during
pregnancy, which is astounding. And if someone's
pregnant, you know, if they're diabetic during
pregnancy, then what happens is less carbs and
nutrition reaches the baby. And often, they
can be underweight. And those babies get overfed,
and that can actually propagate the cycle
of insulin resistance. So this whole cycle
is what we want to interrupt as much as we can. The cholesterol
problems that we talked about, as a result of
this, the triglycerides, the healthy cholesterol,
we're seeing kids are developing these
issues very commonly. So if you've got a family
history of high cholesterol, often the kids need to
be screened as well. And then these are
really the common things. We're seeing kids
that are overworked. They're undernourished. They're overstimulated
from digital toxicity. And they're sleep
deprived as well, too. So my wife and I are now going
out to schools and companies to really talk about how we
can restore more optimal health in young kids, because
they are suffering from a lot of these things. I talk about redefining
our child's card. Maybe they're getting
straight A's here on the left. But on the right, many
of our kids are failing-- physical activity,
time out in nature. What are they eating? Fitness, activity, mindfulness,
all of these things are core parts of this. And then finally, just keep
in mind that those thoughts and emotions, there's a
whole field now called behavioral epigenetics. So when we are actually
experiencing chronic stress, we can flip on the genes
for these chronic health conditions in kids. So we want to make sure we
are managing those emotions as well as we possibly can. OK, so my resources, if you
want to reach out to me, you can always reach out
to me through my blog. I've got some online
programs and ebooks. Actually, my publisher agreed to
release the children's chapter for my book. So if you actually put your
email address in my blog, you will get the whole
children's chapter for free. I've also put a book on
Recharge to help people with chronic fatigue
and energy issues. And if anybody ever
has questions outside of this session, you can always
email me through the blog. I answer every single
question that comes to me. So that was a lot
of information. But we're done right at 1:04,
and we'll have some time to open up for questions. And if there are
kid questions, I'll ask my wife to come up here
and assist me as well, too. So great. Yes? AUDIENCE: Over here, with
your recommendations, I've been able to implement this
thanks to the food at Google, plus what you can get at
Whole Foods, Trader Joe's. I go home. I tried to implement
this with my mother and completely shocked her. We come from a
rice-growing family. Breakfast, lunch, and
dinner is rice-based. And cauliflower rice and
almond flour based things just do not exist in the market. And you don't eat raw vegetables
because of the pesticide problem. So how do you address in a
country like India [INAUDIBLE]?? RONESH SINHA: It's a very tough
crisis right now in India. And in India, the problem
is a lot of Western foods have come into the
diet as well, too. But all you can do when you
go back to India or China or Asian countries is
how can you still-- even if you can't
find cauliflower rice, how can you modify that
rice in a different way? So what I tell people is if
you just have plain white rice, that's going to cause a
glucose and insulin spike. If you were to graph it out,
it would look like this. But you can do a few
things to actually lower that curve on the glucose
and insulin spike. What do you do? Any time you eat vegetables
before carbohydrates, you lower that
reaction by 30% to 40%. So cut up those
cucumbers, tomatoes, and have some sort of vegetables
before you eat the starch. The second thing is what are
you mixing in with the starch? I tell people even if they
don't have cauliflower rice, maybe reduce the rice
amount by a little bit. Mix vegetables into it if your
diet allows it, eggs, nuts, and seeds. So Indian-style biryana
or Asian-style fried rice is much better because when
you add fats, proteins, and vegetables to
a starch, you're going to lower that
glucose response. And then after that
meal, if you inevitably end up eating a meal like
that, even a 10 to 15 minute walk after that meal
is going to lower that. So it's all about
damage control when you go to India
because you're being flooded from all directions
with all types of carbs. What are some of
the things that you can do to kind of dampen that? And then you're right. We do have more options here. You know, India and
Asia are not up to speed on all the different nutritional
options that we have. But clearly, we've had
people benefit very well in other countries
because it's more eating the traditional foods
the way our grandparents did and incorporating
activity into that. We can already see a lot
of benefit from that. So, yeah, we do our
best, whatever we can. But there are a lot of elements
of the Indian diet that are very healthy. You know, the spices, the
way we cook the vegetables, the proteins and healthy
fats are all things. And I think exercise is starting
to become a little bit more fashionable in India. So I think doing
it the right way, focusing on weight
training, these things can help dampen the effects
of the high-carb diet. AUDIENCE: Thanks for that, Doc. RONESH SINHA: Sure, thank you. AUDIENCE: My wife has read
your book page to page, and she has made my life hell. [LAUGHTER] RONESH SINHA: OK,
I apologize, sir. AUDIENCE: A couple of
questions and comments, so the first thing goes
back to the [INAUDIBLE] the guy was working out. Was it probably the stress
that caused his issues with the heart attack? And then you mentioned
CRP for inflammation. Is there a common test
that you can recommend as part of a blood panel? What exactly should we
be asking our doctors? RONESH SINHA: So
let me address CRP. Then I'll talk about the guy
that had the heart attack. So the C-reactive protein is a
very easily measured test that can be done on any blood panel. But my disclaimer is C-reactive
protein, so there's one called the HS, Highly
Sensitive C-reactive protein. That's more of a marker for
the blood vessel inflammation. So I find that more useful. The general CRP can
be elevated if you've got just general inflammation
from an infection, or if you injured
yourself, et cetera. It's very nonspecific. A lot of doctors
don't like ordering it because sometimes it's elevated,
and we really don't know why. But that HSC reactive
protein, especially in somebody that's got a lot
of cholesterol risk factors, et cetera, it can be useful. And the way
traditional doctors use it is because if that's elevated
and your cholesterol is high, they have a lower
threshold for prescribing a statin or a
cholesterol medication. In my practice, I have
a much lower threshold. Well, I'm much more aggressive
about promoting lifestyle changes that lower inflammation
because often when they lower their visceral fat,
they manage their stress. That test does come down. So I will tell you
that some doctors might be resistant to checking it
because if you don't have risk factors, they'll be like, OK. This is a nonspecific test. But it is a pretty easily
accessible test to do. AUDIENCE: Because I had
done C-reactive tests. And my doctor looked
at it, and she was skeptical about
what those numbers mean. RONESH SINHA: Yeah, it's not
part of the standard approach right now. So I think that's why
there's skepticism about it. And the other thing
I would tell you is if your test comes
back completely normal, that doesn't mean that you
don't have inflammation. It's not that. Some people can have completely
normal C-reactive protein, but they still have
other root causes of inflammation in their body. And unfortunately, we
don't have a perfect test. But, for example,
if people are having a lot of digestive
system symptoms, like bloating,
excessive acidity, that's a sign that
their gut health is off. They have inflammation
from that root cause. If they have
eczema, skin issues, so even without the C-reactive
protein, I tell people, be a little bit more
intuitive about other sources of inflammation in the body. Now coming back
to your question-- and it's an important one--
about that heart attack case, that particular case, so I
see all combinations of this. But I am seeing
quite a few folks that are developing heart
disease from overexercising and chronic stress together,
even though those lab results were fairly normal. So one thing is if you
are at high risk for heart disease, what I would say is
make sure you see your doctor. And in some cases, if you've
got enough risk factors, it's recommended to get a stress
test or some sort of screening done before you implement
intensive exercise. I've had a few tragic cases of
heart attacks on treadmills. I had somebody walk outside of
a fitness center and drop dead in the parking lot. And in many of these cases,
what happens is these guys were carrying around very
large, unstable plaques. And now they're in a class
where their heart rate has been taken up to 180 or 190. And in that context,
the exercise actually pushed them over the edge. So with exercise, I tell people
be very gradual in ramping up. And if you've got a family
history and other risk factors, talk to your doctor about
whether any baseline assessments need to be done. OK, yeah. AUDIENCE: My last comment,
going back to the doctors, I'm surprised. So I became aware of this book,
I think, I would say a year or two ago. It is interesting
to see that most of the doctors in the
Valley are still not aware of this kind of thing. So I think part
of your education should be also tailored
towards other institutions. RONESH SINHA: Yeah,
and it's not just-- it's global right now. This approach is more the
exception than the rule. And I'll tell you. One big problem-- because
I know all my colleagues mean well who are doing this. In today's health care system,
doctors get 10, 15 minutes to see a patient. And I just gave you a
very detailed lecture. I do one-hour consultations. But the traditional
medical system is designed for
10 or 15 minutes. It's much easier to
prescribe medications. Most doctors have been trained
about medications and not necessarily lifestyle changes. That's starting to flip a
little bit because now there are fields like functional
medicine, where people are learning more about this. But the main message
here is your doctor is sort of maybe a guide
to help you with issues and order the tests. But your lifestyle
is in your hands. You're the one that has
to find the right content. Sometimes, my
patients, you know, they've got to assemble a team--
a personal trainer, somebody to help them with yoga, maybe
seeing a dietitian that's aligned with them. And then their doctors
order the lab tests, or they might consult with me
or a different practitioner that sort of is aligned with that. But I agree. This is a systemic problem. It's not going to go
away anytime soon. So it's sort of up to us to take
advantage of the information out there. So thank you. Yeah, hi. AUDIENCE: Good to see you. RONESH SINHA: Good to see you. AUDIENCE: I have
an 11-year-old who sees the changes we have
made in how we eat and so on but loves eating and
told me a few days ago, I wish there was no such
thing as overeating. I wish there was no such
thing as bad sugar, et cetera. And he's a little bit on the
heavier side, does swimming three times a week, and so on. I'm not sure how to help him. First, we don't
have any baseline on his different cholesterol
levels and so on. It's not part of what
the doctor checks. At the same time, it seems
pretty harsh to have anything like this be something you
would propose to an 11-year-old. So I haven't got the
update from your book. Does it help with guiding
kids through this? RONESH SINHA: Shally, I'm going
to defer to you because you know how to deal with this. SHALLY SINHA: Yeah, I can talk
first about the parameters that pediatricians use-- RONESH SINHA: You
can come up here now. SHALLY SINHA: --to check
lipid panels in kids. So every time you
go in for a checkup, you might be
noticing that they're plotting your child's weight,
height on growth curves. And then you're seeing
a third curve called the BMI, which is
on percentiles, not a cutoff like in adults. So what's normal depends
on the age and gender. Right now, the guideline
is that if your child is 85th percentile or higher, and
you have family history of, you know, obesity, strokes,
hypercholesterolemia, those kids will get a
fasting lipid panel done. However, now there is also
a general recommendation that, regardless of
family history and weight, children between 9 to 13 should
probably get a baseline lipid panel done. So I think with
pediatricians, they know parental
anxieties are real, and if you just ask your doctor
to please order one, just as a baseline so you know
what you're working with, how seriously you need to
take your child's weight. And maybe your child's
weight is normal, and he just looks a
little over to you. But that's why it's important
to plot the curves first to see where you are. And then I think
that what you said first is that in your
household, you yourself have implemented
those changes already. And that's the
biggest single thing you can do to influence
your child's habits. So I always tell
parents that you can't have a double standard
where you're doing one thing, and you're lecturing
your child to do this. So I think just by example. Now I know it's tough with kids
because they'll go to school. Their peers are bringing,
like, really unhealthy lunches. They're going to
birthday parties. They're getting fed lots
of unhealthy treats. But I feel that on a
day-to-day basis, what they're getting at
home, that's actually building the foundation. So I think that's
the single most thing I would do for my own child. RONESH SINHA: And we're
not recommending, like-- I know I talked
about grams of carbs. But we're not recommending
that for kids that are growing. SHALLY SINHA: No, because
they're still growing, yeah. Yeah, so with kids, it's more
like that pictorial plate. You might have seen that. So just teaching your child,
like Ron had a slide up there, to fill most of it with
a source of vegetables, so starting with a
salad or vegetable soup, and then one quarter
of it the carb, and then one quarter
of it the protein. And if they want
to take seconds, then it should be in that
same ratio, so not just taking seconds of the carbs once
they're done with the plate. RONESH SINHA: And you're really
training their taste buds, too, for later because
many of the kids are averse to eating
any vegetables. So you often say to
just even give them one piece or two pieces
of broccoli or something. SHALLY SINHA: Yeah, I get a
lot of concerns from parents that, oh, my child will
just not touch a vegetable. So I tell parents to just
start with, like, one broccoli stalk or one baby carrot, and
then just go up from there. So every day, just
add that to the plate, and it's an acquired taste. And then also
growing vegetables, I think you had mentioned
concern about pesticides. So I don't know if
your relatives in India could grow their own
vegetables in the backyard. And with kids,
actually that motivates them to try to eat the
vegetables as well, so it's, like, a win-win. RONESH SINHA: Yes? AUDIENCE: A question
about high blood pressure, you didn't talk today. But I see a lot of my
South-Asian friends and family. Even in 20s, the high blood
pressure is very much common. So my question is, are
South Asians genetically prone to high blood pressure? And the second question
is can lifestyle reverse somebody who is
on medication for decades? Can lifestyle change help them
to go off and get the numbers back? RONESH SINHA: Good question,
yes, so blood pressure, I kind of put it on the list, but
I didn't focus on it directly. What I would say
is blood pressure does have a stronger tie to
genetics than the other issues that we talked about. But with blood
pressure, first of all, it is tied to insulin
resistance because when your body has excess
insulin, your blood vessels retain more fluid. And they become stiffer. So often when we reverse
insulin resistance, blood pressure can drop down. The other issue
with blood pressure, though, is a lot of it
has to do with stress and sleep as well, too. So if stress and
sleep aren't managed, then often blood
pressure will stay high. And unfortunately, we live in
high-stress Silicon Valley. Many people, unless
they incorporate those mindfulness
slower practices, it will not get better. And then nutrient-wise,
too, paying attention to the sodium-potassium
balance, so as we lower the amount
of processed foods, which have more sodium, and we
eat more plant-based foods, lower sodium and
higher potassium naturally will lower
blood pressure. So there are definitely some
ways you can address that. But even having said that,
I have some elite athletes in my practice. And they're on blood
pressure medication because both parents had it. They just genetically have
stiffer blood vessels. So I think there is a
potential for normalization. But in some cases, the genes
can play a strong role there. But, you know, definitely
the sleep and stress are major factors. Yeah, thanks for
bringing that up. AUDIENCE: So I have a few things
in common with what you said, in terms of being
brought up in Calcutta and also having twin boys. RONESH SINHA: All right. AUDIENCE: My question
is this whole approach to medicine seems to be very
cognitive and mechanistic in the sense-- you know, I use the
word mechanistic just to point out that
it's numbers based. And it's almost like
you have to have this app watching
you and advising you through every
moment of your life, versus a very intuitive
way of choosing your diet. Your body is speaking
to yourself, your mind. And that's how I
saw my grandparents picking what they want to eat. So is that even feasible
in this day and age, to allow your body
to speak to you and point you to the right
choices, versus doing it in a very numbers-driven,
cognitive way? RONESH SINHA: Great point,
you know, most of my talks have a slide of my-- I literally have a slide of
my grandmother and then me with all these wearables
attached to it. And I make the point
that our grandparents have this sense of intuition. What I would say is the goal
was to get to that point you're talking about. Right now, the
signal-to-noise ratio is crazy, because of our
stress and sleep deprivation, how much sugar and
stuff we're eating. So people don't even know what
it feels like to be healthy. So often, I drive
them with the metrics, so then they have
something to hang onto. And that empowers them. But as you can, I
haven't worn a Fitbit now for probably three months
because I intuitively know when I'm being sedentary
and when I'm being more active. But at some point, yeah, you
listen your body's signals, and you don't
become programmatic. And I've got to say that
Shally can attest to this. I can be very protocol-driven
with my workouts. And she's like,
you know, you just need to chill out
and relax today. So she knows better
than me sometimes that there are days where I've
got to sort of do something that's more intuitive
and based on my feelings and not based on
my schedule of I've got to do boot camp
every Monday, Tuesday. But I think it's
absolutely possible. And when I see patients
[INAUDIBLE] at a certain point, I'm like, you know, just listen
to your body at this point. You've got some rough markers. How's your waistline doing? How's your weight,
you know, et cetera? But I think the goal is to
get back to that intuition. So I'm glad you brought that up. Thanks for that, yeah. So I'll go online
to this question. "How do I find a primary
care physician who is aware of the more stringent cutoffs
for measuring health of South Asians and/or work
with one who isn't?" So luckily, these cutoffs now
have a lot of data behind it. The World Health Organization
and other entities have set these cutoffs. So many doctors just
don't know about this. But this isn't off the cuff. So I think you can still
educate your doctor. Many of our patients have gone
and educated their doctors. Within our group, we're
pretty well versed in this. But if your doctor is
not aware of this-- you know, the main
thing you want with a doctor is you want
a doctor to be open-minded. So even if they're
knowledgeable, if they're willing
to learn and use some of these
cutoffs and things, then I think that's
perfectly fine to do. Next question,
"can you talk a bit about why vegans
and vegetarians have much lower rates of diabetes
in population studies?" Got a link there. A recent randomized study
showed a low-fat vegan diet with no calorie
restriction was more effective at
reversing type 2 diabetes than a controlled
diet with calorie control. Great question, so the
main thing I'm going to say is, again, it depends on what
sort of vegetarian or vegan diet is being consumed. So I know I said a
lot of negative things about a vegetarian
diet, but I'm talking about the typical Asian or
Indian-based vegetarian diet. If somebody is eating the really
plant-based type of vegetarian, so if you look at a typical
Western vegan or vegetarian diet, usually that's
much more plant-based. Western vegetarians tend to
do more physical activity, exercise, and the
other entities. So when you look
at those studies, you're definitely going to
see a lower rate of diabetes. So I'm definitely not
anti-vegan or vegetarian. But people just have to analyze. Are they eating the
healthy version of that? The other thing
is when people are eating a lot of the extra carbs
in the typical Asian diet, they're missing out
on micronutrients. And those micronutrient
deficiencies, like vitamin D and
magnesium, et cetera, those can also raise
the risk of disease. But there are a lot
of studies out there. Now I tell people
a general point. You are your own study. You can find studies that
are pro-vegan, vegetarian, anti-vegan, vegetarian,
but know the basics. Make the changes, and then
follow your numbers before, mid-term, and after to see
what the response is with you. And then go from there. AUDIENCE: I know you talked
about micronutrients. Can you elaborate a
little more about what is the spectrum
of micronutrients we should focus on? RONESH SINHA: Right,
so what I would say-- and you can fill in some
for maybe kids as well, too. But for adults, vitamin D
I've been talking about a lot. So vitamin D is a critical
one, so definitely that's something we want to
assess, especially if we have an indoor lifestyle. Us that have skin
tones that are darker, we tend to be more
vitamin D deficient because we're not getting
as much of the UVB rays. Iron deficiency is
something that I guess you'd see more in kids. But in adults, depending
on their risk factors, that can be a factor, especially
with the vegetarian diet. SHALLY SINHA: Women also. RONESH SINHA: Women in
particular, too, obviously, absolutely. SHALLY SINHA: [INAUDIBLE] RONESH SINHA: Right, so that's
the other micronutrient. Now magnesium is tricky. You know, magnesium is linked
to a lot of the conditions that we talked about. But a standard blood magnesium
test won't give you that data. I tell people that if we're
having these, most of us are magnesium-depleted,
just because of our soil. So I think making
sure you're eating magnesium-rich foods is key. For vegetarians and
vegans and even some of our non-vegetarians, we do
see B vitamin deficiencies, too, so B12 and folate. It is worthwhile
to check for those and making sure you get
adequate sources of that. So those are at
the high level some of the major micronutrients. Am I missing some,
maybe in the kids? SHALLY SINHA: Yeah, I mean,
just to take a step back, so when we say
micronutrients, we're referring to vitamins
and minerals. And these are crucial in
all the enzymatic processes in your body. So macronutrients are just
proteins, carbs, and fats. So then to fill in on how
those are metabolized, that's where your vitamins
and minerals come into play. So aside from the examples Ron
gave, particularly in kids, I would definitely emphasize
calcium and zinc as well, and iron for sure. And, you know, for
example, with iron, they've even shown that
iron-deficient kids can perform poorly on
math and language tests. So it even affects
their brain development if they're low in any of these
micronutrients, so very key. And then just in general,
with even adults, if you're low in micronutrients
like iodine and selenium, it can affect your
thyroid function. And it may not show up on
your thyroid hormone tests, but you may be
experiencing symptoms of low thyroid function. So these are where those
micronutrients really play a big role. AUDIENCE: Sorry. Just a quick,
follow-up question, especially for the kids, if
we feel like through the diet they're not getting a
full spectrum of these, do you suggest just giving
them over-the-counter vitamin supplements? SHALLY SINHA: Yeah, I
get that question a lot. The problem is that
they're just not absorbed as well from a multi-vitamin. And a lot of times, it's
because it's complementary. So for example, taking iron with
something high in vitamin C, you'll absorb a lot more
of it than if you take it with something that's
really high in calcium. So it's like synergistic. And also the vitamins
are just maybe not going to provide all that
the child needs because they do have growing bodies. And I think just
setting the good habits early on on eating a
well-rounded diet, not just kind of teaching them to take a
pill, that just will go-- yeah. RONESH SINHA: Yeah,
and one other point, too, with the
vitamin absorption, so the fat-soluble vitamins
like A, D, E, and K, those are fat-soluble vitamins. So when you're eating vegetables
with some healthy fat in it, it does increase the
absorption of that. So that's the whole
point about making sure we've got the proper
nutrients around them. AUDIENCE: Can I just piggy
back off that question? RONESH SINHA: Sure. AUDIENCE: Sorry. So how about
probiotics to improve the brain-gut connection and all
of that, for kids, especially? RONESH SINHA: For kids, yes, so
basically for adults and kids, we're all fans of
gut-healthy diets. And we try to introduce
it through foods as much as we can. But some people, at
least in the adults, they might need probiotics for
optimal gap sort of coverage of those needs that they have. We always say that probiotics
are sort of a temporary place holder strategy. While you're sort of eating
more gut-friendly foods, probiotics can help. But some people do find
that long-term-wise, they're thriving on the probiotics. And there's no reason why
they can't continue that. SHALLY SINHA: I think in
kids, I don't normally put them on probiotics
unless they just got, like, an antibiotic course for
an ear infection or something. But otherwise, I
normally recommend lots of yogurt daily in the diet. And then in the
Indian diet, like, any of the pickles,
that's also loaded with probiotics, so just getting
it naturally from the diet. AUDIENCE: Like, for
attention deficit or things of that nature that
are behavioral, do you see a difference in
choosing that kind of diet and a correction
in the symptoms? SHALLY SINHA: Definitely,
with my ADHD patients, even lowering the sugar
content in their daily diet sometimes makes a
huge difference. I've had parents
of autistic kids take out all the
preservatives in their diet. That's made improvements. So I think the diet connection
with kids' brain development is so key. So definitely what
they eat definitely manifests in the way
they behave and the way their cognitive
functions occur, yeah. RONESH SINHA: I'll go
online for this one. "Can you talk a little bit about
good carbs versus bad carbs? We know from dozens of
interventional studies that whole grains and legumes
are associated with lower risk of chronic disease. But these are carbs. Many people are afraid
nowadays of all carbs." OK, so this is a
really important point, because I did put carbs
at the center of this. But there clearly are healthy
carbohydrates out there, like lentils and beans, that
are part of our staple diet. But what I was talking
about is especially if you have an
insulin-resistant condition and that parking lot is
closed or you're not active, these even healthy carbs in
abundance are causing issues. Most of the patients
that I see in my clinic are not drinking Coke
or eating pizzas. They're having grains. They're having quinoa. They're having lentils. And we're still seeing a lot
of these conditions happen. The good news is once they
implement the right lifestyle strategies-- they're
physically active-- then absolutely you can
reintroduce some whole grains and lentils and
see how people do. It all comes down to that
individual experimentation. But I don't want
people to be afraid. And quite frankly, legumes
are very gut-friendly foods. Our gut loves that sort
of prebiotic fiber that sort of reaches them,
the healthy gut bacteria. So I don't want people to
become phobic about this. But just be aware that
quantity can make a difference. And if you have a condition
like insulin resistance, we've really got to be
careful about the amounts. So for this protein source,
just a simple answer, I put a couple of
options on that list. And then I would refer people
to my blog on the protein link. Yeah, so if your diet
allows dairy, for example, so even good quality
paneer is fine. Obviously, yogurts for the
probiotic source are OK. Some quantities of cheese is OK. Quinoa is fine, too. I mean, quinoa, I know, can
be high on the carb side. But it's a great
source of protein. Nuts, seeds, nut
and seed butters, obviously, are good sources. If vegetarian diet allows
some egg consumption, then we're big fans of having
eggs in there as well, too. So at a high level,
those are some. And like I said, lentils
are a good protein source. Yeah, and then
organic soy, you know, if there's no issue with
soy, then doing non-GMO soy sources can be another
option as well. AUDIENCE: I mentioned
that I sometimes take whey or other
supplements after a workout because they are calories. But they are protein-intense. RONESH SINHA: Yeah, for
a lot of my slender folks that are trying to add more
muscle mass, I'm a fan. You know, what we
do with our kids-- and I'll do it after
some workouts-- I'll do a good quality
whey protein shake. And there's some good data
behind whey protein supplements in terms of lowering
cholesterol, diabetes, heart disease risk. So just make sure
it's a good quality. What I mean by that is
a lot of whey protein shakes have
artificial sweeteners and other ingredients. But especially for
vegetarians, where it's tough to get enough protein
into the diet to build muscle, I think the whey protein
supplements are fine. AUDIENCE: That's even
on non-workout days, like, to make up
for protein content? RONESH SINHA: You can do that. Yeah, but again, the whole
protein is more bioavailable. So as long as you're not using
it as a meal replacement, because you want to
get the other nutrients around that protein,
but I think, yeah. Sometimes, my vegetarians
might do a whey protein shake when they're on the run or
as a mid-afternoon snack. I'd rather have them do it
through that way than getting unhealthier sources of protein. SHALLY SINHA: I wouldn't do too
many protein shakes for kids. It puts a lot of load
on their kidneys. RONESH SINHA: "Is eating Indian
ghee or egg yolk, three to four a day, OK?" A lot of mixed opinions
on this, this all comes back to the point
about personalization. To give you an idea, there
was a "New England Journal of Medicine" study done on a
gentleman in a nursing home who was eating 18 to 20
egg yolks every single day for, like, 8 to 9 years. And he had a
perfectly cholesterol. Like, it could not
even be better. So he has the genetic capacity
to actually metabolize that. But some people that have
those genetic markers that I talked about, they
may not do well with that. Their cholesterol
might actually go up. So again, I think
you'll want to start probably not as aggressively
as three to four a day. You can up it a
little bit and then recheck your cholesterol to see
if you might be fat-sensitive. But again, the egg
yolks should be in the context of eating other
vegetables and other foods. We don't want to
become just focused on excessive amounts
of fat in the diet. Eating Indian ghee in most
of our patients is fine. You know, it can actually
lower inflammation. If they're not saturated fat
sensitive, in healthy amounts, we find that it is
good for health. "Does duration between
meals, timing of meals, and combination of
certain meals matter? I hear a lot of Asian tips
to eat certain foods only at a certain time of day or
not to eat some foods together. What's the truth? How does it relate to
intermittent fasting?" Great questions,
I've done a couple of blog posts on fasting. I think it does make
a big difference. And, again, I'm giving
general guidelines. But the overall approach to
eating every two to three hours to speed up your metabolism,
I think that can really be a negative pattern for
a lot of people because, again, if you've got
insulin resistance, and you're eating every
two to three hours, you're spiking
insulin constantly. So for many of
those folks, having more gaps between nutrient-dense
meals is a better approach. They're actually going
to burn more body fat by doing intermittent fasting. So we have to think
about the context. For other patients,
for example, women who might have adrenal
issues, nutrient deficiencies, they might have
to eat more often. They might have to eat more
frequently to get the nutrients into their system. But meal timing is a
real critical thing. A lot of us are very
structured in our approach to how we eat our meals. But sometimes longer
spaces to recover from high-carbohydrate
meals maybe the night before is a good way to do it. So don't be programmatic
that every day, I'm going to eat every
two to three hours. Our lives are very flexible. Some days, you binge
eat the night before. Then we have to
correct the next day by maybe doing some intermittent
fasting to allow our liver to recover. So that's a very
high-level point on that. There's more nuance to it. And like I said, refer
to the blog and book for more information on that. Great. So thank you to the people
online, in the room, for joining. Hope that was helpful. Thank you. [APPLAUSE] Thanks, guys.
