Intermittent Fasting HACKS To Lose Weight & REVERSE AGING | Dr. Pradip Jamnadas

1. 0:00 – 6:45

   Graded fasting protocol: cut sugar, skip meals, then fast

   1. PJDr. Pradip Jamnadas0:00

      I said, "Look, right now just get rid of all those things. I want you to eat a natural diet. So eat as much as you want, but of the right food. And I want you to do that for approximately-

   2. RCDr. Rangan Chatterjee0:16

      There's that one thing, fasting, that's hitting so many different things, isn't it? It's reducing your insulin. It's encouraging autophagy. You know, we've not mentioned really apoptosis yet. It's encouraging apoptosis, stem cell production, growth hormone. So many different things are being activated, and actually, if we could get a drug to do any one of those, we'd be sort of shouting about it. But, but this one thing does all of them, which is, which is incredibly fascinating. Look, I, I really want to understand because, um, I, I want to talk more about the science a bit later on in this conversation, but in terms of getting really practical for people, like if we, if we compare fasting to, let's say, movement, right? So people, if they want to move more, they know they could start off with a 15-minute walk around the block. You know, they want to do a bit more, they make it 30, 40 minutes around the block. Uh, then they might start jogging. Some people might want to do a 5K or a 5K walk or even a run, a 10K. Some people want to do a marathon, right? So there's different grades of movement, and so what are the different grades of fasting? You know, where can people start? You know, r- super, super simple. What are the benefits of that level? And then how can people progress up depending on their state of health, depending on their goals? You know, I, I think that would be quite a useful way at looking at fasting and making it really practical for people.

   3. PJDr. Pradip Jamnadas1:42

      Uh, a good, great question. So my general advice in my office, and, and all my nurse practitioners do the same thing with our patients, is look, first thing you need to do is cut out all the sugars. Because if you go into a fasting with your regular diet pattern, you're gonna have a very nasty experience. You're gonna feel very hungry. You're gonna go through withdrawal from sugar. You're gonna feel terribly hungry, sweaty. You may even actually have worse symptoms. So the first thing we gotta do is, look, just we explain to the patients that your body is not supposed to consume so much sugar. You know, we consume about, about more than 10 tea- 20 teaspoons of sugar a day in one form or the other. So the first thing I tell my patients is, "Look, you need to get rid of all artificial foods." Sugar is manufactured. Sugar is artificial. Sugar is a poison for the body. You need to cut out all sugar, all processed foods. Processed foods, anything that is made in a factory, anything that has a barcode on it is suspect. Anything that's been pulverized, anything that has been made into a powder, get rid of everything. You need to eat foods in their natural, whole form, and that's the first thing you do. So forget fasting right now. The first thing you're gonna do is just change your diet. I want you to eat whole foods. So I have a chart in my office that's an anti-inflammatory diet, and it contains all the whole foods. I said, "When you look at the food in your plate, you need to be able to recognize it. Yes, this is what this is. This is what this..." And they say, "What about meat and chicken and fish?" I said, "No problem, as long as it is grass-finished meat, organic chicken, organic eggs, and you can have some, uh, some turkey, but you must have vegetables in their normal, natural state." And first thing you need to do is do that. So get rid of all the bread, all the bagels, pastries, all the things that are coming in a box, spaghetti included, pasta included. I said, "Look, right now just get rid of all those things. I want you to eat a natural diet. So eat as much as you want, but of the right food. And I want you to do that for approximately two to three weeks." No fasting right now. No, no fasting right now. So that way, they get used to that idea-

   4. RCDr. Rangan Chatterjee3:58

      Yeah

   5. PJDr. Pradip Jamnadas3:59

      ... that I'm going to first just change my diet. And then after two to three weeks, then I bring them back inside and I say, "Okay, so now that you've been doing this, how do you feel?" They say, "Doc, I really do feel much better." Now I say, "Now you're gonna learn to skip meals. So step number two is skip meals. Wake up in the morning, I'm not hungry for breakfast. Skip it. Come around to lunch, have your lunch, have your dinner. Next day, uh, have breakfast, but skip your lunch. Um, the next day, skip your dinner. So learn to just skip meals. And look, you feel fine. Nothing bad happened. You were perhaps a little hungry. You got over it by drinking a glass of water. Drink lots of water during the daytime." So I do that for another two weeks or so. See? I'm doing it gradually, just like your athlete. You can't go do your 5K right now. You first need to build into it. So for a couple of weeks, I make them just skip meals randomly. Then I sit down with them and say, "Now, this week, five days a week, I want you to have only two meals, and these two meals are gonna be within six hours of each other so that you're gonna have 18 hours that you're not gonna eat at all and only drink water. No calories in those 18 hours whatsoever. You can have water, black tea, black coffee, but no calories whatsoever." And they say, "Oh, gosh, that's great." And they do that for about two weeks. So for two weeks, Monday to Friday, two meals within a six-hour window period. So they're 18 hours, they are fasting. They do that for two weeks. Weekends, I let them have fun because they're with their family. So I say, "You can have breakfast, you can have lunch, dinner, but no snacks in between." So most you're gonna have on weekends is three meals on the weekends. Then they do that for another two weeks. Then I say, "Okay, now is when you're really gonna start your fasting. Monday, Wednesday, and Friday, I want you to skip that second meal also. Now you're only gonna eat one meal on Monday, Wednesday, and Friday. That's it. The rest of the days during the week, you're gonna have your two meals. Weekends, you can still have your three meals." So I gradually get them into that, and most of the time- Patients are able to do it this way

   6. RCDr. Rangan Chatterjee6:04

      Yeah, yeah

   7. PJDr. Pradip Jamnadas6:04

      When I go then, when I try to make them go to once-a-day eating or time-restricted feeding within a six-hour window from the get-go, um, my failure rate is much higher. So I make them do it gradually.

   8. RCDr. Rangan Chatterjee6:16

      Yeah, yeah

   9. PJDr. Pradip Jamnadas6:16

      And then, then they self-empower themselves, and then eventually I come to a three-day water fast, which we can talk about-

   10. RCDr. Rangan Chatterjee6:22

       Yeah, yeah

   11. PJDr. Pradip Jamnadas6:23

       ... and the biochemistry of that.

   12. RCDr. Rangan Chatterjee6:24

       I mean, I love that. You know, I, I love chatting to fellow clinicians. Uh, I, I love chatting to researchers as well, I must be honest, but clinicians like yourself, you know, you've got the real-life experience, not just what does the laboratory study say, what happens in the lab. No, that you're dealing with real patients who are probably quite scared, and, you know,

2. 6:45 – 14:44

   Who the program is for and why coronary calcium scoring matters

   1. RCDr. Rangan Chatterjee6:45

      that, that, that sort of protocol you just took us through, just to make it really clear for people, you know, what types of patients are you recommending this in? You're a cardiologist, of course, you know, you practice in America. I don't know the exact differences on who gets referred to a cardiologist in America compared to here in the UK. So my guess would be that people are, you know, sick on some level. You know, they've, they've either got angina already, uh, maybe they've already got ischemic heart disease, maybe they have already had a heart attack. You know, you're obviously seeing those kinds of patients. But then we could take it one step further, which is that we know in America, there was a recent study, wasn't there? Well, not that recent, a few years ago now, that showing that maybe over 80% of Americans are not in good metabolic health, which is really quite incredible. So I'm imagining pretty much all of your patients who come to see a cardiologist are already metabolically unhealthy, are already having a degree of insulin resistance, and therefore problems with their health and wellbeing. So, you know, maybe help us through that a little bit, because what I, what I wanna be really clear on, someone who feels that they're in good health, they're of, you know, a decent weight, they don't have any health problems, is that the approach that they should be doing as well? Or are you specifically talking about patients who are already a little bit sick?

   2. PJDr. Pradip Jamnadas8:10

      No, no, no, no. You're, you're sort of right. No. What I'm talking about here applies to just about everybody. In fact, it's more than 80%. I think it applies to more than 90% of the bit. Now, of course, the cohort that I see in my office are patients who already have coronary artery disease-

   3. RCDr. Rangan Chatterjee8:26

      Yeah, yeah

   4. PJDr. Pradip Jamnadas8:26

      ... or they already have had a heart attack. So those patients are kind of easy for me, uh, to, to, to convince that, "Hey, listen, you already had a heart attack. Now, you want another one? Well, you already have had two stents, and when you're gonna get the third one. So you need to do this, and I'ma put you on this program." Okay, that's fine. But then there's another cohort of patients who come to me, and I do a coronary calcium score, and it's high. But they're asymptomatic, and they've passed their stress test. So let me just tell everybody who, who doesn't know about coronary calcium score, because this is so important, and I'll tell you why it really it's important. So it's a CT scan, low-level radiation of the heart, and it looks at the amount of calcium buildup in your coronary arteries. So it tells you you already have atherosclerosis. So there's no guessing that, oh yeah, you know, your cholesterol, your blood pressure, your weight, and therefore your risk of having a heart attack in the next 10 years is such and such and such. We gotta plug you into a formula. No. This is, do you have the disease? Yes or no? Do the scan. Yes, you have disease. Do the stress test. Pass my stress test. Why? Why did I pass my stress test when I've got calcium in my arteries? Well, you pass the stress test because your blockage in your artery caused by the calcium is less than 70%, 'cause it takes a blockage more than 70% to reduce the blood flow in it, and then you may have symptoms, or you may pass, I mean, fail your stress test.

   5. RCDr. Rangan Chatterjee9:52

      C- can we just back-- Can, can we just back it up a second for people? Like, what is ischemic heart disease? What is atherosclerosis? What is a stress test? Because I think there'll be some people listening who probably may not be familiar with those terms, and I think it would be quite useful to sort of set that foundation, if you don't mind.

   6. PJDr. Pradip Jamnadas10:08

      Yeah. Yeah, they're very important. So atherosclerosis is the buildup of plaque in the walls of the arteries, and they occur everywhere, in your neck, in your brain, in your legs, but most importantly, in your heart. So when the artery, the walls of the arteries develop calcium in them, it's atherosclerosis. You cannot get atherosclerosis without calcium. Actually, you can, but very little. Most of the time, there's a lot of calcium with it. So the calcium is a surrogate for the plaque buildup in the walls of the arteries, and that calcium buildup, the atherosclerosis, can cause two problems. It can narrow your artery down on the inside, so the pipe becomes narrowed, and therefore that causes ischemic heart disease. Ischemic heart disease, lack of circulation, lack of blood flow going down that artery. Therefore, the muscle is deprived of blood, and the patient may experience pressure, tightness, heaviness in the chest, particularly on exertion. That's called angina. So angina, chest pain, is because of lack of circulation due to the plaque, which is picked up by the calcium and a positive stress test. Now, a positive stress test, stress test is where you exercise you, or we use chemicals to simulate an exercise, and it can tell us the consequences, the consequences of the blockage. Is my blockage more than 70% or less than 70%? If it is more than 70, it may reduce the blood flow in the muscle, and we'll pick that up on the stress test. The stress test can be a nuclear stress test or an EKG stress test. But now, if your blockage is more than 70, you are more likely to experience chest pain and the effects of the lack of circulation in the heart muscle. And depending on the location of that blockage and how much muscle is getting the effects of the lack of circulation-

   7. RCDr. Rangan Chatterjee12:01

      Mm-hmm

   8. PJDr. Pradip Jamnadas12:02

      ... your cardiologist may opt to either put you on medicines or, if you're having very bad symptoms, maybe even put a stent inside, which we can talk about. But what I really want to stress here is that you can have a blockage, atherosclerotic, calcium-laden blockage that is less than 70%. You pass your stress test. You have no chest pain. And those are the patients that I'm seeing in my office now, because they're coming in, they're getting their coronary calcium score, which they would not have otherwise.

   9. RCDr. Rangan Chatterjee12:31

      Yeah, yeah.

   10. PJDr. Pradip Jamnadas12:32

       'Cause you go to a primary care physician's office and they say, "Oh, yeah, your stress test is good, your cholesterol's fine, your blood pressure's okay. Yeah, keep going." And the guy gets a heart attack within a year or two years, and say, "What happened to me?" Well, because you already had the plaque, you just didn't know it. So the coronary CT scan that we do, low level, looking for the calcium, picks up the calcium in the walls of the arteries and quantitates it on a score that goes from, like, zero to 4,000. Over 100 is significant. Between 100 and 400 is, is v- very significant, but over 400 is critical. That means you really have a lot of calcium in the walls of the arteries. So these are the patients who, coming in, they do the scan, and I see that they have all this calcium in the walls of the-- Now, I turn around to them and say, "Did you know that you already have atherosclerosis? You already got it."

   11. RCDr. Rangan Chatterjee13:26

       Yeah.

   12. PJDr. Pradip Jamnadas13:26

       And we have studies that show that that coronary calcium is gonna predict whether you're gonna have a heart attack or a coronary event or a stroke or even total mortality more accurately than all the other blood tests put together. So now I say, "Now, do I have your attention? You already have..." You see, you've got to motivate the patient, and this is my, um, this is my carrot. And I mean, look, you have atherosclerosis. Now I want you to do my program. Now I'm gonna look for some parameters on your blood test. I'm gonna see what's causing this calcium buildup. And the patient will say, "But I'm fine." I said, "Yeah, but you didn't just build this up. Something is making your coronary calcium build up, so let's find out what it is." So I do a CRAFT test, I do a full physical examination, I'll do tests, uh, advanced lipid panel. These are tests that I do in the office to see, and then I might even inquire into their gastrointestinal health. I will do a whole evaluation to see why this patient's building up this atherosclerosis, and part of the treatment program is gonna be my fasting program, which I think is the number one program for this. So those patients, um, are very happily motivated because I show them their coronary calcium score. I say, "Look, look at your picture."

   13. RCDr. Rangan Chatterjee14:41

       Yeah, yeah.

   14. PJDr. Pradip Jamnadas14:41

       "This is it. Check it out. You got this calcium."

3. 14:44 – 19:55

   Metabolic syndrome, insulin and weight as a side effect

   1. PJDr. Pradip Jamnadas14:44

      Another group of patients, they come in, the 80% that you're referring to have metabolic syndrome. So for the, for the sake of the audience, I'm just gonna tell everyone what metabolic syndrome is.

   2. RCDr. Rangan Chatterjee14:54

      Yeah, yeah. Thank you, thank you.

   3. PJDr. Pradip Jamnadas14:54

      This is a, a derangement of your metabolism, and basically it means that you're, you're overweight, your body mass index is greater than 25, um, and you have, uh, an increased abdominal girth. All the weight is around the belly, and there's actually a ratio that you can do between the waist and the belly. The belly is increased. And then the HDL, the cholesterol, is low, and the triglycerides are high, and, um, they have borderline high blood pressure. Now, when you look at all these numbers, what's the common theme that comes to mind from everything I've already said? It's insulin. It's all about in- insulin lowers your HDL, increases your triglycerides, increases your abdominal girth because all the fat is down there. Remember what insulin does? Insulin puts all your calories, excess calories and frequent calories and because of the high insulin levels, puts it where? Into the liver, pancreas, and visceral gut. And that fat is totally different from the fat that you put on all over your body when you overeat. You may not overeat just eating a lot of fats and, you know. Okay, that's different. But the fats that are produced under the influence of insulin by the liver, de novo lipogenesis, the new fats that are created, the glucose has to be converted into a storage product. The storage product is that fat. That fat in the liver gets d- deposited in the liver, pancreas, visceral gut, is very inflammatory. Its composition's totally different. You do a biopsy of it, you'll find inflammatory cells in it that are producing tons and tons of interleukin-6 and tumor necrosis. Bad stuff. So metabolic syndrome, although you have these basic features, when you do additional biochemistry on them, you will find that they have increased CRP level, which is a blood test for inflammation, and if you can do even further testing, you will find that they have very high interleukin-6 or tumor necrosis factors, and they have small, dense LDL particles indicative of inflammation. So these patients come into the office for prevention, or they're sent to me because they have a low HDL, and, and, and these are the patients that also I'll do the, the p- uh, the, the fasting program. So some patients are motivated to go into my fasting program and lose the weight that way. 'Cause, see, the weight, by the way, I gotta tell everybody, the weight is a side effect of the metabolism that's gone wrong.

   4. RCDr. Rangan Chatterjee17:21

      Yeah, yeah.

   5. PJDr. Pradip Jamnadas17:22

      You fix the metabolism, the weight comes down as a side effect.

   6. RCDr. Rangan Chatterjee17:25

      Yeah, yeah.

   7. PJDr. Pradip Jamnadas17:26

      It's not really a weight loss program. It's a metabolic program in which one of the side effects is that your weight comes back down to the way it's supposed to be.

   8. RCDr. Rangan Chatterjee17:34

      Yeah, yeah.

   9. PJDr. Pradip Jamnadas17:34

      Comes back to the way it was supposed to be. So, um, so these patients come in a- a- a- and, and they get referred to me, so I almost invariably do a coronary calcium score on them. But even if their coronary calcium score is not very high, the metabolic derangements are going to make coronary calcium in the future, and I motivate these patients to start making the lifestyle changes by showing them that their metabolism's off. Now, these metabolic tests are not being offered by every doctor's office and, and nobody-- 'cause it takes a lot of effort.

   10. RCDr. Rangan Chatterjee18:03

       Yeah, yeah.

   11. PJDr. Pradip Jamnadas18:04

       And the insurance companies sometimes don't want to pay for it, like the advanced lipid panel. Um, sometimes they pay for it, sometimes they don't. So what I did in my office is I developed a program where it's a cash paying. If the insurance doesn't pay for it, okay, this is how much it's gonna cost you. But get the test done. It's a good investment, and I have to show them that it's-

   12. RCDr. Rangan Chatterjee18:22

       Yeah, yeah

   13. PJDr. Pradip Jamnadas18:22

       ... that it's gonna change their life.

   14. RCDr. Rangan Chatterjee18:24

       Yeah.

   15. PJDr. Pradip Jamnadas18:25

       But you're absolutely right that this metabolic derangement is, is not 80%, it, it's probably more than that.

   16. RCDr. Rangan Chatterjee18:31

       Yeah, yeah.

   17. PJDr. Pradip Jamnadas18:31

       Uh, uh, and it's very... Because I'm seeing it in children. I mean, [laughs] I just the other day I saw a mother bring in her 16-year-old, and I'm like, you know, and I said, "You, uh, I'm not a pediatric cardiologist, but there you go." Um, she had all the derangements already at the age of 16.

   18. RCDr. Rangan Chatterjee18:46

       Yeah. Th- this is-

   19. PJDr. Pradip Jamnadas18:47

       And it's, it's-

   20. RCDr. Rangan Chatterjee18:47

       ... this is so, it, it's so fascinating, and I think, you know, I, I think I've read a study where they're saying nowadays atherosclerosis starts in some children even under the age of 10, I believe you can see in some kids, which is, you know, you know, clearly no one wants to be hearing that. No parent wants that for their child. We don't really want that across society. What, what I find really interesting is the, the different groups of patients who come in to see you. You know, the proper, the ones who've already got established heart disease, and obviously, hopefully, a lot of them will be motivated to go, "Okay, Doc, tell me what to do, and I'll do it." But then you've also got some who are probably coming in for prevention. You know, what's the state of my heart? What's the state of my bloods? You know, is there anything I need to do? And the approach I can see is, is very similar. But you also, you know, you're, you're, you're sort of encouraging them to go all out and cut out all of the, uh, highly processed foods. You know, you're saying all breads, all pastas-

   21. PJDr. Pradip Jamnadas19:51

       Absolutely

   22. RCDr. Rangan Chatterjee19:52

       ... which for m- which for many people is very difficult.

4. 19:55 – 24:57

   Compromises on bread, motivating patients and coming off medications

   1. RCDr. Rangan Chatterjee19:55

      Now, some people, in the UK at least, would call that quite extreme, okay? Um, now, I also have used that approach, successfully with my patients, so I can, I've absolutely seen the value of that. But I think it's worth talking about that. Does everyone need to go to that extreme? And I know a lot of breads these days are highly processed. They've got about 10, 15 different ingredients in. They have a high glycemic index, they spike our blood sugar. Whereas I know some of the kind of German breads, uh, like the rye bread sometimes, and some of the, uh, like the, in the UK at least, the square-shaped German breads often can have a much lower, uh, sugar response. So I guess what I'm trying to get at is all patients presumably say, "Look, I'm gonna try it," but they can't do the whole thing the way you would ideally want them to. Um, you know, are there some common obstacles? Are there some sort of common compromises you have to make with people when they can't go the whole way?

   2. PJDr. Pradip Jamnadas20:53

      No, no, you're, you're absolutely right. I mean, if you gr- you grew up on toast and, and white bread, and it's gonna be very hard to do. So it just depends on, on their stats. Now, if they come in purely for prevention, they're not overweight, but they do have some family history, it might be difficult for me to convince them that-

   3. RCDr. Rangan Chatterjee21:09

      Yeah, yeah

   4. PJDr. Pradip Jamnadas21:09

      ... "Hey, listen, you need to cut out all the, all, all the bread." But clearly, if they're overweight, you know, it's, it's basically convincing the patient that, "Look, you're overweight. You, you have metabolic disease. Uh, I can see some parameters here on the blood tests, uh, or you already have coronary calcium in your arteries." And then explain to them the consequences of that. That is not just that you're gonna get a heart attack. You're also at risk of getting dementia when you grow older. You're gonna get peripheral vascular disease. You're gonna get renal failure. Such a big link between kidney disease and heart disease. I said, "So take your pick. What, what, what do you want? What do you want?" And cancers. Obesity is also related to cancer. So sitting down and between my, myself and my staff, explaining to the patients that, hey, listen, this is not just about, about your heart, this is also about your whole life. This, this is a-

   5. RCDr. Rangan Chatterjee21:56

      Yeah, yeah

   6. PJDr. Pradip Jamnadas21:57

      ... really a holistic approach. This is, this is gonna affect everything. This is gonna affect the way you're gonna retire, and what your retirement gonna be like, and are you gonna be aware of your own retirement, and are you able to think? Um, because Alzheimer's is going off the roof too. I mean, we have a huge increase in the amount of dementia that's going on. And, and I'm one of those who believes that much of that is also vascular. It's all vascular. I think everything, you're as old as your arteries, you know?

   7. RCDr. Rangan Chatterjee22:21

      Yeah, yeah.

   8. PJDr. Pradip Jamnadas22:21

      Um, uh, so, so what's your arterial age? Let's, let's look at that. And so I think that making these dietary changes and cutting out the bread, uh, yes, you're absolutely right, is a difficult one to sell. Uh, but at least even if they cut down or move to pumpernickel bread or, or, or, or even sourdough bread is better, because at least it has some benefit on the microbiome. But at least make some compromises.

   9. RCDr. Rangan Chatterjee22:44

      Yeah, yeah.

   10. PJDr. Pradip Jamnadas22:45

       And start. Start. At least do something. Um-

   11. RCDr. Rangan Chatterjee22:48

       Yeah, yeah

   12. PJDr. Pradip Jamnadas22:49

       ... you know, and I think that that's, that, that, that's the key thing, is motivating the patient to think more long-term also, and not just think coronary artery disease. Everything that I tell the patients to do for their heart, I tell them straight up front, "This is gonna keep your eyesight. This is gonna keep you from getting dementia, you know, renal disease. This is gonna help you from hopefully also decrease your risk of cancer, joint disease, back problems," I mean, name it. It, it, it really has so many ramifications. So yeah. So again, it comes down to what we said in, right in the beginning of this talk, that we have to motivate the patient.

   13. RCDr. Rangan Chatterjee23:21

       Yeah, yeah.

   14. PJDr. Pradip Jamnadas23:21

       I need to get into your brain, make a change in you so that you know that this is the right thing to do, and then it resonates with you. Yes, this is right, and then see the practical results of it. And it's a slow process, gradual process, but, you know, we've, we've done this.

   15. RCDr. Rangan Chatterjee23:38

       Yeah, yeah.

   16. PJDr. Pradip Jamnadas23:38

       We've gotten patients off blood pressure medication. We've got them off insulin. You, you know, the biggest achievements I've had in the last, uh, few years now is getting patients off insulin, and it makes me feel so good when I do that. And all through this program. They come in, and they're already taking 25 units of insulin twice a day.

   17. RCDr. Rangan Chatterjee23:54

       Yeah, yeah.

   18. PJDr. Pradip Jamnadas23:54

       And now they're on nothing. Uh, and their A1Cs are so good.

   19. RCDr. Rangan Chatterjee23:58

       Yeah. You-

   20. PJDr. Pradip Jamnadas23:59

       And-

   21. RCDr. Rangan Chatterjee23:59

       You, you love it, and I bet the patients love it as well, don't they?

   22. PJDr. Pradip Jamnadas24:02

       Oh, gosh, c- coming off insulin, coming off blood pressure medications-

   23. RCDr. Rangan Chatterjee24:06

       Yeah, yeah

   24. PJDr. Pradip Jamnadas24:06

       ... um, coming off cholesterol medic- Do you know how many patients walk into my office and, and, and they're on tons of statins and, and I do a coronary study on them, and the score is zero? Score is zero. They have no coronary calcium, and they're taking all these statins and, and they're hobbling around with all these muscle aches and pains, and I'll just stop the statin. So that's another thing, you know, empowering patients to know that, you know, there's no one treatment for all. That yes, your cholesterol level is a little high And therefore, you have to be on a statin. I try to individualize-

   25. RCDr. Rangan Chatterjee24:38

       Yeah, yeah

   26. PJDr. Pradip Jamnadas24:38

       ... the treatment for the patients based on, on, on what, what's doing to your body. You know, you have, you, you have a decent advanced lipid panel, and, uh, we can make some dietary changes here so that you don't get any f- more coronary calcium, but you don't have to be on a statin. Empowering the patients-

   27. RCDr. Rangan Chatterjee24:54

       Yeah, yeah

   28. PJDr. Pradip Jamnadas24:54

       ... to do that as well. Yeah.

   29. RCDr. Rangan Chatterjee24:55

       But what I ... You know,

5. 24:57 – 31:58

   Withdrawal, 12-hour versus 18-hour fasts, women and South Asian risk

   1. RCDr. Rangan Chatterjee24:57

      thinking about your approach, uh, um, because I've been using similar approaches with my patients for a number of years now, and I think we see a different subset because I'm a general practitioner and you're a cardiologist. Of course, there's a huge crossover given how common type 2 diabetes is, how common metabolic syndrome is, and ... But it's interesting. So you go, before you approach any form of fasting, you have a three-week period where you, you know, in inverted commas, try and clean up the diet. You try and reduce the processed foods that they're gonna consume, increase the whole natural foods, which is just gonna put them in a much better state for when you then bring in your 18-hour fast.

   2. PJDr. Pradip Jamnadas25:44

      I-

   3. RCDr. Rangan Chatterjee25:44

      So what, uh, which I, which is really interesting, I, I take quite a softly, softly approach, I guess. I always start with a 12-hour fast, which some people-

   4. PJDr. Pradip Jamnadas25:52

      Right

   5. RCDr. Rangan Chatterjee25:52

      ... wouldn't even call a fast. Um, but I think pretty much every human being should be able to go for 12 hours in every 24 hours without eating food. And if you can't currently, that's okay, but it would indicate that you are, you know, you have some sort of dysfunction, some metabolic dysfunction somewhere. Otherwise, you would be able to, 'cause some people, you know, say, "I really struggle with that." And I say, "Okay, it doesn't mean that that's not a good thing for you. It just means at the moment, your biochemistry and physiology is not able to support that, so let, let's, let's work on that and get you to a point where you can." And then, yeah, for the right patient, I also increase it up gradually. Um, so I find that super interesting as, as kind of just to notice a difference because there's no right or wrong, is there? There's just we're all trying to empower our patients, and we're, we're all kind of biased, I guess, by our own experiences as to what we have found, uh, working with patients. So I found that really interesting. Also, are most of your patients men? And the reason I ask that is because, of course, heart disease, we hear a lot about killing men. Of course, it affects women as well. Um, but also there is this question mark that many people have over fasting as, okay, it kind of works for men, but maybe it's not so good for women. Um, I have my own view on that, but I, I wonder if you could share some of your thoughts on that.

   6. PJDr. Pradip Jamnadas27:17

      Yeah. So the first part was, uh, 12 hours versus 18 hours. Um, you know, there's two things that I'm concerned about when patients start, uh, fasting. One is the withdrawal, um, and I think that withdrawal is, it, it comes in two shapes. Uh, there's mental withdrawal that it's, uh, I'm, I'm a Pavlovian reflex. I have to eat at 8 o'clock in the morning. I've done that for so many years. The other one is a true biochemical, um, addiction at the level of the brain. So that really concerns me, that that's why I do this period to come in-

   7. RCDr. Rangan Chatterjee27:53

      Yeah, yeah

   8. PJDr. Pradip Jamnadas27:54

      ... because that gets them rid of the addiction, 'cause I think addiction is a real issue.

   9. RCDr. Rangan Chatterjee27:58

      Yeah, yeah.

   10. PJDr. Pradip Jamnadas27:58

       They're addicted Pavlovian-wise, but they're also biochemically in the brain, and some of them really do go through withdrawal symptoms. And they say, "You know, I felt terrible. I, I started sweating, and I had these intense cravings," and, um, and I said, "God, this sounds like heroin withdrawal." A- and I think it's real. Um, so that's why I do this, just skipping meals and gradually getting into it. But once, how long does that take? That's the question. How long does that take? And in my experience, I've been doing this, it takes three weeks. At the end of three weeks, I can pretty confidently say that the patients have gone through their withdrawals-

   11. RCDr. Rangan Chatterjee28:35

       Yeah, yeah

   12. PJDr. Pradip Jamnadas28:35

       ... and they're gonna be now okay to take on the 18 hours, and that's why I do it that way. And the withdrawals are very real because the foods have addictive properties. Sugar is definitely addictive. We know that. We know dairy products have, um, casomorphin, um, which actually are addictive. So you crave those things that you, that, that, that doc has told you to, to, to skip the meals on and all that. But I think that after three weeks, they're done. And I tell patients, "It's not gonna be easy. For the first three weeks, you're gonna get a lot of cravings. You need social support. You need to structure your life. You need to do your shopping during the times that you're gonna be eating that meal otherwise, so you keep your mind busy, and, and you gotta get your seven hours of sleep." And so, yeah. So w- the, the withdrawal issue is very important. That's why I do this gradual stuff. Uh, and then the answer to the second part, that women, uh, definitely, w- women are not exempt from CAD and heart disease. And, and, and something that applies to you and me is, uh, Asian women too. Did you know, did you know that the instance of coronary artery disease in Indian women is actually higher than Indian men? But it's just that they, they don't get diagnosed, and, and they don't seem to complain that much, so they don't come to, to, to the doctor's office. But actually, I've seen worse coronary artery disease in Indian women in my office than in Indian men. And in Indians in general-

   13. RCDr. Rangan Chatterjee30:00

       Yeah

   14. PJDr. Pradip Jamnadas30:00

       ... they have far more coronary artery disease than Caucasians, so it's a huge problem. So I think that women are, are, are certainly a, a, a, a population that is not exempt from coronary artery disease. Now, the fasting programs in women, uh, there are some data to suggest that they may not benefit as much as, as men, but overall, I think that what I've seen is that they also seem to benefit just as much. Um, so I, I-

   15. RCDr. Rangan Chatterjee30:28

       Yeah, yeah

   16. PJDr. Pradip Jamnadas30:28

       ... I don't make much distinction between men and women. They come in here, I work them up the same way. Um, I'm very aggressive with the women as well.

   17. RCDr. Rangan Chatterjee30:35

       Yeah, yeah.

   18. PJDr. Pradip Jamnadas30:36

       Especially, especially, uh, women from South Asia. Uh, the, the, when they walk in, they've got my antennas up. In fact, any South Asian that walks into my office, my antennas are up because-

   19. RCDr. Rangan Chatterjee30:47

       Yeah, yeah

   20. PJDr. Pradip Jamnadas30:47

       ... um, they are what I call toffees You know, they're thin on the outside, they're fat on the inside, and, and they're metabolically very deranged. And, uh, there are specific things that I-

   21. RCDr. Rangan Chatterjee30:58

       Yeah

   22. PJDr. Pradip Jamnadas30:58

       ... tell them about fasting and dietary recommendations for their diet. And, and the reasons, uh, have to do with, uh, vitamin K2 as well, which I'm finding absolutely fascinating these days.

   23. RCDr. Rangan Chatterjee31:09

       Yeah, yeah. We'll be back to the conversation in just a moment. Now, many of us struggle to find time to eat all of these incredible whole foods. That's why I'm a big fan of good quality whole food supplements like this one that's been in my own life for over three years now. It contains over 75 whole food source ingredients, vitamins, minerals, pre and probiotics, and can help us support our energy, focus, digestion, and our immune system. Athletic Greens are giving my audience a fantastic offer, one year's free supply of vitamin D and five free travel packs with your first order. You can see all the details at athleticgreens.com/livemore or simply click on the link below. Now, back to the conversation.

6. 31:58 – 48:54

   Carbs, fructose, food order and other tricks to lower insulin

   1. RCDr. Rangan Chatterjee31:58

      You've mentioned in your books, you mentioned in this conversation that chronically elevated insulin is problematic for a whole variety of different reasons. Yes, for the developments of type 2 diabetes, of putting on weights. Also, you know, a lot of people aren't aware that it increases blood pressure, increases fluid retention, increases, uh, a type of cholesterol called VLDL, very low density lipoprotein, which can be problematic. And so for a variety of reasons, we wanna lower that. So there's two broad ways I'm getting that we can do that. One is through a diet that does not constantly push up insulin, and the other way is with a form of intermittent fasting or, you know, bringing in some type. So if we, if we start off with food and diet, you mentioned low carb earlier on in this conversation. Of course, we know how divisive, um, the diet landscape currently is. In your experience, if we're thinking about a diet, food choices that don't spike insulin too much, what are the kind of principles you like your patients to follow?

   2. SPSpeaker33:08

      Yeah, and I think this is where, um, you know, there's always a lot of difference in opinion, there's low carb versus high carb. And I actually think that there's a huge difference even within carbohydrates. So the, the problem is not generally the carbohydrates, but the processing that makes the biggest difference. So if you look at the glycemic index, which is, um, you know, which looks at carbohydrate containing foods, sees how much insulin tends to go up and glucose tends to go up, they tend to go up together, uh, of certain foods. What you see is that unprocessed carbohydrates tend to cause a lot lower spike in insulin than, than processed foods. So you take cereals like Cheerios and stuff, they're really, really high. You take a very refined product like white bread, uh, just very, very high. But then you look at something like boiled potatoes, and it's just extremely low. They're both carbohydrate containing foods. Um, so there, there's a big difference even within carbohydrates. Beans. Beans are carbohydrates. They have a different type of amylopectin. They have amylopectin C versus amylopectin A. Their digestion is completely different. They're still carbs. So trying to simplify it to just carbs is difficult because you could eat a lot of beans, and who gets fat eating beans? Like, very few people. Um-

   3. RCDr. Rangan Chatterjee34:36

      Are you talking like black beans, kidney beans, these sort of things?

   4. SPSpeaker34:39

      Yeah, all beans.

   5. RCDr. Rangan Chatterjee34:40

      Yeah.

   6. SPSpeaker34:40

      Yeah. The type of carbohydrate they contain is amylopectin C, which is harder to digest and therefore leads to much lower blood glucose levels, much lower insulin levels. Um, but insulin is sort of that key. So even within carbohydrates, so, so people think, well, one of the things is to cut carbs, which is, which is a reasonable thing, but cutting the refined carbs does a lot better. 'Cause you have to understand that a lot of countries, a lot of cultures have had high carbohydrate intakes and in the past have never had a big problem. So China, for example, was classic in the '80s. It was eating 300 grams a day of carbohydrates, almost all white rice. And there was almost no obesity. This is 1980. Then, of course, recently they, they, they started eating a lot more processed foods, a lot more sugary foods. Now their obesity is just exploding. But it was not just the carbs.

   7. RCDr. Rangan Chatterjee35:32

      Wh- why do you... This is really interesting for me. So white rice is a refined carbohydrate. Why do we have societies with high volumes of carbohydrates who are not putting on weights and who are not getting type 2 diabetes? And that example you use of China there is really interesting. 300 grams of white rice a day you would think would spike insulin [laughs] and would, um, you know, cause people to get sick, but it wasn't.

   8. SPSpeaker36:01

      Yeah. It wasn't.

   9. RCDr. Rangan Chatterjee36:02

      And, and what if... You know, one of the theories I put forward in my first book was this idea that maybe in the West, in the m- the modern world in which we now live, where people are chronically stressed, they're chronically underslept, they're chronically underactive, and they're eating a lot of highly processed foods, all together, that's creating the perfect conditions for high levels of insulin resistance. And I thought, well, maybe the low carb diet has a particular utility in modern, stressed out cultures. I, I don't know, have you got any comments on that? And how do you explain that in the 1970s they were eating this in China and not getting sick?

   10. SPSpeaker36:41

       I think there's a few things. One is that the amount of sugar they were eating was just almost zero.

   11. RCDr. Rangan Chatterjee36:47

       Yeah.

   12. SPSpeaker36:48

       So sugar, which is fructose, is metabolized quite differently than glucose. So when you metabolize glucose, all your cells in the body can use glucose. When you metabolize fructose, only the liver can use fructose. So the fructose goes straight to your liver, and there it gets converted and causes fatty liver, it causes all kinds of things when you're eating too much fructose. Um, so it can get converted back into glucose, but for a lot of reasons, it just gets turned into fat through de novo lipogenesis. You get fatty liver, you get insulin resistance, which causes hyperinsulinemia. So the fructose is actually much worse for you than the glucose, in my opinion, because, you know, if you are 150 pounds, you have 150 pounds of body that's using glucose versus sort of five pounds of liver that can metabolize fructose. So the fructose is much, much more, uh, obesogenic, I think, than the, uh, glucose. So therefore, the practical side is that sugar and sweet things like that are just much more fattening than starchy foods.

   13. RCDr. Rangan Chatterjee37:55

       So maybe you're saying then in China back then, because they're not having much fructose-

   14. SPSpeaker38:00

       Yeah, almost zero

   15. RCDr. Rangan Chatterjee38:01

       ... th- therefore, they can actually, their bodies can handle the 300 grams of white rice each day, whereas on the background of a lot of fructose, which, which is, of course, how many of us live these days, too much sugar, too much fruit juice, all these kind of things, maybe with a background of that, suddenly the white rice starts to become problematic?

   16. SPSpeaker38:22

       Uh, yeah, I think so. I think the fructose, uh, really makes that, that much worse. But the other thing is, um, that there's different reasons why... And, and two, they weren't eating all the time, right? They weren't-

   17. RCDr. Rangan Chatterjee38:34

       Yeah

   18. SPSpeaker38:34

       ... eating constantly. It's not like they're eating eight times a day of white rice. And the third thing I think that's sort of always overlooked, because it doesn't fit into this neat little square, is that there's different reasons why we eat. Like, there's the hunger, the nutrition part of things, which we think is important, but in this day and age is probably the least important of the reasons that we eat. There's the habits, right? You eat because it's time to eat. That's really the only reason, and you eat because it's delicious. So if you take any diet that is monotonous, so no matter what diet it is. So you could eat, say, say you love pizza, but I give you pizza breakfast, lunch, and dinner. Okay, very soon, [laughs] much sooner than you think, you are going to be so sick of pizza that if I continue to feed you pizza, you're just gonna say, "Okay, I'm gonna eat as little of this pizza as I possibly can until I'm no longer hungry, because I just don't like to eat it." It's the same thing with white rice. If you eat white rice and vegetables every single day, three meals a day, which is, you know, what they're eating in China, like, different types of, you know, vegetables with white rice. Pretty soon, you're gonna be like, "I will eat the rice because I'm hungry. As soon as I stop being hungry, I am stopping eating," 'cause I know w- I, I, the, the hedonic effect of food, the pleasure-giving sense of food, goes away when it's, it's completely monotonous. So you can eat all that and, you know, you're not gonna overeat it because you don't want to.

   19. RCDr. Rangan Chatterjee40:17

       Yeah.

   20. SPSpeaker40:17

       You just wanna make sure you're not hungry, and therefore, any monotonous diet always works because you've just very quickly run out of things that you want to eat.

   21. RCDr. Rangan Chatterjee40:28

       Yeah.

   22. SPSpeaker40:29

       So what we've done, of course, in the modern age is we've introduced all kinds of varieties of food, which keeps us eating beyond the we're full sort of stage. I've got my nutrition. I'm done. I don't wanna eat anymore. We never get that state because we're always like, well, you know, we wanna keep eating. And then you get around it by snacking, because even if you... There's lots of good things to eat, so you go to a buffet, you know, all-you-can-eat restaurant. You know, after a certain point, you have to stop. Like, you can't keep going. It's, you know, if you've eaten everything and somebody says, "Hey, why don't you have a bit more of this pork chop?" You'd be like, "Ugh, that's gonna make me throw up," right? It's the same pork chop as you ate, like, 20 minutes ago, but you're now full. So the, the point is that if y- if you take away the sort of pleasure-giving part of food, then you're gonna be able to control a lot of overweight-

   23. RCDr. Rangan Chatterjee41:29

       Yeah

   24. SPSpeaker41:29

       ... obesity, which is what the white rice was, right? It was monotonous. It was just every single day was the same thing. Like, I, I can tell you, I, I, I, I ate rice a lot growing up because my, my parents were immigrants. They came from, from, uh, Hong Kong. We re- ate rice probably every single day. So yeah, I liked rice a- a- all right, but, you know, until you're full, then that's it. Like-

   25. RCDr. Rangan Chatterjee41:53

       Yeah

   26. SPSpeaker41:53

       ... you know, I, I don't wanna eat more than I [laughs] have to because I've eaten too much of it a- a- already. So, so that's why it's always, you know, people say, "Oh, therefore carbs are good," or you have the Kempner rice diet from the '40s. "Hey, that proves that carbs aren't the enemy." It's like, no, no, no, it's very complicated. Like, you, you can't just simplify things into-

   27. RCDr. Rangan Chatterjee42:15

       Yeah

   28. SPSpeaker42:15

       ... like, this food is good and this food is bad, right? So it, th- there's a lot that goes into sort of understanding-

   29. RCDr. Rangan Chatterjee42:22

       Yeah

   30. SPSpeaker42:23

       ... it, and satiety plays a big role in that. That is why the things that are most successful at controlling weight are hormonal agents that control your appetite. So nicotine is a classic example. It, it actually suppresses your appetite. People notice this when they stop smoking, that their appetite goes up, and it's probably 'cause it, it was chronically suppressed. Same thing with semaglutide, the drugs that, some of the drugs that are used now. But anyway, so, so it means that the carbohydrates are not the only thing that matters.
7. 48:54 – 54:54

   Starting intermittent fasting and the muscle-loss myth

   1. RCDr. Rangan Chatterjee48:54

      Jason, moving to fasting, intermittent fasting, right? If someone's kind of heard what you've had to say so far and is thinking, "Okay, all right, um, I'm interested in trying intermittent fasting," where would you encourage them to start? And, and before you answer, I also wanna say, one of the things I think is so great about- The practice of intermittent fasting is that it doesn't really matter what dietary tribe you belong to, you can still practice this and get benefits to it. So I think it cuts through straight away through all that noise. Um, so yeah, maybe, maybe some tips for people on, on where they might want to start.

   2. SPSpeaker49:37

      Yeah, I think that the, the first place to start really is just to go back to sort of, uh, you know, eight hours, 10 hours of eating sort of thing. Um, you know, you, you... If you wanna eat sort of breakfast at 8, 9 o'clock in the morning and finish by, like, 6 o'clock in the evening, and then let the rest of the time be fasting, you know, you're talking about a eight, nine, 10-hour eating window, then maybe 14 to 16 hours, and that, and that's relatively easy to do. And of course, it's something that people have done for, for many, many, uh, years. So cutting out the snacks, cutting out the late-night eating. And then, you know, so if you cut out the eating after dinner and push your breakfast a little bit later, then, then you're automatically gonna get that, that period of time, and that's a great place to start. And then you can experiment. You can go longer or fa- uh, or shorter, depending on what you like. Um, but I think that's, that's probably a good place to start off with. That's gonna be safe for everybody. Um, you know, there's no, there's no problems with, with anything. You're still gonna be eating a relatively normal, um, you know, meal schedule and so on. But, you know, there's just so many, or there used to be at least, so many sort of, uh, myths about fasting, about how it was so damaging to you and all this. I, I think, you know, it's important to get that right information as well. People used to think, "Oh, well, you know, it's, it's gonna burn muscle." And it's like you hear this all the time, [sighs] and I'm always like, "Okay, if you're an elite athlete, sure, maybe, maybe that's something you have to be mindful of." But for most people who are not elite athletes, um, you're just sort of regular, uh, people, you know, this idea that it's gonna burn muscle is still very much ingrained. You see it out there. Lots of people talk about it, and it's like, [inhales] do you really think that our body is just so stupid that we would store calories as glucose and body fat, but the minute that you don't eat anything, you're gonna burn muscle? Like, do you think that we survived as a species to become the dominant species on Earth because our body is so intrinsically stupid? Like, it's sorta like storing firewood, you know, for the winter, and then as soon as it gets a little cold, you chop up your sofa and throw it in the fire.

   3. RCDr. Rangan Chatterjee52:00

      [laughs]

   4. SPSpeaker52:00

      Like, what? Like, what? Like, why are you storing body fat if you plan to use that, that, that muscle? It's, like, ridiculous. And I think it, it's a, it's a huge misunderstanding of the physiology. So I have a video about the five stages of fasting, and there's a period of time in there that actually is called gluconeogenesis. So when you think about the physiology of fasting, there's a lot of good things that happen. But essentially, your body goes from eating food, then it starts using glycogen, which is sugar. It's, it's basically chains of glucose that are stored in your liver. And then after glycogen, then there's a short period of gluconeogenesis, which is protein, and that's where people say, "Wow, that's your, that's where you're breaking down muscle." And you kind of have to say, "No, protein is not the same as muscle." Protein is a lot of things. There's lots of excess protein in our bodies. Skin, for example, is protein. Connective tissue, the thing that binds it all together, is protein. When you break down proteins, your body's gonna break it down and then rebuild whatever it is that you need. So if you need muscle, you will build it. If you don't need it, it won't build it. Like, the only thing that builds muscle... What, what builds muscle and loses muscle is not how much or how little you eat or protein you eat. It's the exercise that you do. Like, I'd love it if I could eat and build muscle, but I don't. [laughs] Like, it doesn't happen, ever, as much as I want it to. And it's the same thing. When you're breaking down protein, it's not necessarily muscle. If you're using the muscle, it's not gonna get broken down. But what you are gonna do is break down the skin, the connective tissue, the stuff that you don't need, and this is this process called autophagy where your body's actually going to break down organelles in the body because it's not necessary, and it's a process of cleaning out the unnecessary stuff. So people who did intermittent fasting, we have people lose, you know, 100, 150 pounds. We haven't sent anybody for, um, skin removal surgery, because that was protein that was removed, not fat. And that's all anecdotal, I know. It's not sort of proof. But we have a lot of people who say, "Wow, my skin has tightened up too." It's like you don't get that with just body fat loss. That's protein loss. If you, if you look at the amount of protein on the human body, in somebody who's overweight, it's, it's far in excess. They have more protein than somebody who's, who weighs less. It's not just the fat. It's all the stuff that helps to support the fat, the, the blood vessels, the skin, the connective tissue, right? And that all also has to go-

   5. RCDr. Rangan Chatterjee54:36

      Yeah

   6. SPSpeaker54:36

      ... with that. So yes, there is a period of breaking down proteins during the period of fasting, sort of around 18 to 24 to 30 hours, something like that, but it's not necessarily a bad thing. It doesn't mean your body is breaking down muscle.

   7. RCDr. Rangan Chatterjee54:50

      Yeah.

   8. SPSpeaker54:50

      You will lose muscle when you don't use muscle.

8. 54:54 – 1:01:48

   What you can drink while fasting and why fasting raises energy

   1. RCDr. Rangan Chatterjee54:54

      So you're saying start off for people maybe a 10-hour eating window, as you say. M- let's say 8:00 AM till 6:00 PM is your eating window. Out with that, what, in your view, 'cause you take a lot of people through these fasting programs, I know, in your clinic, what are they permitted t- to do outside that eating window in terms of drinks, uh, and other things? That's the first question. And then going beyond that- It's like what benefits then might people, once they start there and go, "Okay, this is pretty easy. I can do that. I'm feeling better, lost a bit of weight. I'm sleeping better. I feel lighter," what are the benefits, or why should some people consider going further? 'Cause I think in your clinic d- am I right in saying that sometimes you take people into 36-hour fasts, 48-hour fasts, those sort of things. So maybe just, yeah, just, just, just walk us through that if you, if you will.

   2. SPSpeaker55:49

      Yeah. So, you know, a classic fast is water only, but really you don't have to be that strict. There's no rules. Like, uh, you know, when you're talking about fasting, there's two main variables. One is the length of fast, and two is what is allowed during that fast. And you can put... Y- there's lots of things. So tea, for example, is something that I recommend for a lot of people. Um, you can drink coffee. And then those really don't have too much effect on, you know, your body. There's no calories in, you know, green tea, and, uh, it really doesn't have much effect. On the other hand, the coffee and stuff, it's gonna have... The coffee and tea, they both have things like stimulants, like caffeine, and that may keep your sort of energy, uh, you know, your, your metabolic rate a little bit higher. So yeah, maybe there's a little benefit from those, although the effect is relatively small. So teas, coffees, herbal teas, those are all great to do. Then you get into things that are more clearly food, uh, so things like bone broth, for example, and then people even take like small salads and stuff within that fasting window, you know, if they get very hungry, for example. And those are, you know, people think, "Well, you know, I just broke my fast," right? "I have to start all over." That's not what happens, because what happens is that when you're fasting, you're trying to force that insulin level down. So if your insulin level's going down, your body's going to switch towards using your, your, your stored calories, not, not the food. If you break that fast with, say, you know, oh, I had, you know, um, some bone broth, yeah, your insulin's gonna blip up for a little bit, but it's a very small amount, and then it's just gonna start going back down again. It's not gonna have a huge effect. So even if you take something during that fasting window, it doesn't mean that all of your progress has been lost and you have to start from scratch again. So y- you don't have to worry so much. But generally, I tend to tell people, you know, just stick with like teas, coffee. If you put a little bit of cream in the coffee because that's what you're used to, go ahead. It's not gonna make a huge difference. But don't put like the whole, you know, carton of cream in it. Then, then you're talking about food more than anything else. And then the other thing is in terms of the benefits of fasting, why continue with it? Um, there's a lot of reasons. Like if you think about the physiology of what happens during fasting, there's a lot of good things that happen. People always assume that they're gonna be tired, uh, during fasting, but that's not actually what happens. So if you, if you, if you don't eat, there's a very sort of stereotyped response. That is, insulin's gonna go down, but certain other hormones are gonna go up. And one of those hormones is the sympathetic nervous system and growth hormone. So both of those go up as you fast. Sympathetic nervous system is part of this, uh, sort of, uh, parasympathetic is sort of relaxing, sympathetic is sort of stimulating. It's a sort of fight or flight response. So it's, it's, it's, uh, the hormones involved are mostly noradrenaline and adrenaline. So you actually activate the sympathetic nervous system when you don't eat, and this is sort of basic first year medical school stuff. It's, s- it's, it's a number of hormones called the counterregulatory hormones. You get a spike of this counterregulatory hormone in the morning, um, around 5:00 AM, 4:00 AM, 5:00 AM and it sets you up for the day. It's pushing the sh- the, the, the, the, the calories, the energy b- into the system so that you have energy for the day ahead. So that's why you don't necessarily have to eat the minute that you get up, because your body's already started fueling yourself from its stores. And because you're having higher levels of sympathetic nervous system, you're gonna be able to concentrate better. You're gonna have more energy as you fast, not less energy. Like think about it, uh, you know, if you have a, a lion who just ate, it's sort of sleepy, just wants to lie there and digest. But you have a hungry wolf. Is it sort of like falling over because it can't concentrate? No. The hunger is what makes it dangerous, because it's dialed in, it's concentrated, and it's got energy to burn. It's just getting its energy from its stores, not from its food, and that's because you've... And it, you know, again, it's not some voodoo magic [laughs] psychology. It's just physiology. Your body is ramping up at the time that you're fasting.

   3. RCDr. Rangan Chatterjee1:00:12

      Yeah.

   4. SPSpeaker1:00:13

      Well, that's great. You're gonna have more energy. I've had people come in, you know, women and, and their husbands would be like, "I can't keep up with her anymore," like, "She walks so fast, I can't even... I, I have to tell her to slow down." And so she's like, "Yeah, it's because I have so much energy." It's like, yeah, because now you're releasing that energy.

   5. RCDr. Rangan Chatterjee1:00:32

      Yeah.

   6. SPSpeaker1:00:32

      You've now finally allowed your body to access the stores of energy. By allowing insulin to fall by fasting, you're allowing your body to s- access this huge store of calories, this [laughs] hundred thousand calories that you've had stored away, that you've never been able to access before because insulin is always blocking you.

   7. RCDr. Rangan Chatterjee1:00:51

      Yeah.

   8. SPSpeaker1:00:51

      Now you have access to this energy, they're like, "Whoa, okay, let's use it. Let's use it." Your body's pumping up the, the sympathetic tone. Some people actually can't sleep because, because they're so pumped up when they're fasting. But then they can focus better. We know that people, you know, in terms of their mental abilities are, do better with fasting. So it's, it's a-

   9. RCDr. Rangan Chatterjee1:01:10

      Yeah

   10. SPSpeaker1:01:10

       ... fascinating, uh, process, but a lot of good stuff there.

   11. RCDr. Rangan Chatterjee1:01:13

       It's, it's just crazy how many people have never, ever experienced anything like that because of what we were talking about right at the start of this conversation, where, you know, over 50% of the US population who don't work in shifts are consuming foods over 15 hours a day. So they're nowhere near- Able to actually experience these things that you're talking about. And I think another thing which I often think about with fasting is that humans have been fasting for [laughs] donkey's years, right? If it was dangerous, how would we possibly have survived this far?

9. 1:01:48 – 1:06:07

   Fasting with diabetes medication and the problem with medical education

   1. RCDr. Rangan Chatterjee1:01:48

      Now, on that, I think a couple of caveats, and I know you deal with a lot of patients with type 2 diabetes. Do people, in your opinion, need to be careful if they are taking blood sugar-lowering medications or injecting insulin? I think we should just sort of briefly mention that in case people jump straight in.

   2. SPSpeaker1:02:09

      Yeah, absolutely. So remember that when you're, um, fasting and your body's gonna be using glucose, stored glucose, whether it's in your blood or whether it's in your liver, uh, if you're taking medication in addition to lower your blood glucose, you could possibly go too low. And yes, it can be very, very dangerous. So you, if you're on medications, you should always speak to your doctor. But for a long time, people used to say, "Well, that's why type 2 diabetics can't fast." It's like, no, that's why you have to be careful, because the thing about the fasting is that it is a way to help lower your blood glucose. If you're lowering it with fasting and you're taking your medication, then you'll go too low. But it doesn't mean that you should not fast.

   3. RCDr. Rangan Chatterjee1:02:51

      Yeah.

   4. SPSpeaker1:02:52

      It means you need to take less medication. It means y- you're overmedicated, so you need to adjust that medication.

   5. RCDr. Rangan Chatterjee1:02:58

      Yeah.

   6. SPSpeaker1:02:58

      Not that the fasting was wrong. Because the, you know, this is a natural way to lower your blood glucose. Like, what could be better than that? You're gonna-

   7. RCDr. Rangan Chatterjee1:03:09

      Yeah, but we, we, we don't see that as doctors, do we? You know, it's like-

   8. SPSpeaker1:03:11

      [laughs]

   9. RCDr. Rangan Chatterjee1:03:12

      ... no, it's, it's a g- given that you stay on the medication. Oh no, this is dangerous, so adding in fasting. It's like, well, hold on a minute. It's just, you can think of it as a third medication and just think, oh, if I'm gonna add this one in, maybe I need to take this one down or take this one off. But it, it's not... It, it speaks to this wider problem that we don't, as a profession, in my view, give things like fasting or changes in food quality the same priority, the same level of importance as, you know, tinkering this medication by 10 milligrams here. Do you know what I mean? It's kinda like, no.

   10. SPSpeaker1:03:46

       No, absolutely.

   11. RCDr. Rangan Chatterjee1:03:47

       It, and it's, it's very frustrating.

   12. SPSpeaker1:03:49

       It is because, um, for example, you'll have, um, if somebody is on insulin, for example, and their blood glucose goes down, so what is the advice that we as a profession give? Well, eat something, right? It's like, okay. Well, sure. At that one specific time, yes, I agree. But in general, if you're going down, it means you're overmedicated, because I'm giving you this insulin to get your sugars low and your sugars are going too low, so you're overmedicated. So you need to reduce the dose. But we don't think that way because we think, okay, well, what you should do, and this is, I, I've heard actually dieticians say this all the time, "You need to eat to cover your insulin." It's like, what? [laughs] So if you take insulin, your sugars go low, then you eat. What do you think is gonna happen? You're gonna gain weight. If you gain weight, what happens to your type 2 diabetes? It gets worse. Why don't you instead not eat, take less insulin, and then you're gonna lose weight? As you lose weight, your type 2 diabetes will get better. But you're absolutely right, like we've gone in the wrong direction thinking that the, the medications are what's good for us, and everything else has to fit around that. And it's, it's part of the problem is medical education because, a- again, I've gone to so many meetings, and these are given by the heads of, you know, diabetes associations and stuff, right? And they'll go, "Okay. The number one, two, and three, uh, treatments for type 2 diabetes is, you know, diet, diet, diet." Right. Okay, great. Then they spend the next 59 minutes out of that 60-minute lecture telling you about drugs. So the message to all the doctors, these are training doctors and established doctors, is that, yes, we will give you lip service about diet and lifestyle. But what we're really here to talk about-

   13. RCDr. Rangan Chatterjee1:05:38

       Yeah

   14. SPSpeaker1:05:38

       ... is meds, right? And that's wrong.

   15. RCDr. Rangan Chatterjee1:05:40

       Yeah.

   16. SPSpeaker1:05:40

       That's absolutely wrong thing because-

   17. RCDr. Rangan Chatterjee1:05:44

       Yeah

   18. SPSpeaker1:05:44

       ... think about this simplistically, right? [laughs] Type 2 diabetes is largely a dietary disease, and we're using drugs to control a dietary disease, but you're not going to get as much effect as you think you will because you're not focused on the root cause, which is the diet.

   19. RCDr. Rangan Chatterjee1:06:02

       Eating less-

   20. SPSpeaker1:06:03

       Mm-hmm

   21. RCDr. Rangan Chatterjee1:06:03

       ... is also something that might be helpful, right?

   22. SPSpeaker1:06:07

       Yeah.

10. 1:06:07 – 1:13:30

    Immunometabolism, fasting and immune renewal

    1. SPSpeaker1:06:07

       So this is another field I've, I've just got fascinated with, um, and that's the, the immunomet- metabolism. I don't know if you've heard anything about this.

    2. RCDr. Rangan Chatterjee1:06:16

       I love that word.

    3. SPSpeaker1:06:17

       Yeah. [laughs]

    4. RCDr. Rangan Chatterjee1:06:17

       Love it. Immunometabolism.

    5. SPSpeaker1:06:19

       Chipping two words together. Yeah.

    6. RCDr. Rangan Chatterjee1:06:20

       I like it.

    7. SPSpeaker1:06:21

       And it's only just in the five, last five years that it's really kind of popped up, um, and people have started looking at this. But metabolence- metabolism is basically breaking down of, um, the major components of our diet, so the protein, carbohydrate, and fats into energy and building blocks that our cells can use. And people might hear things about metabolic rate or I've got a good metabolism, these kind of things that people say. Um, and w- you know, metabolism and the immune system are really intimately entwined, and I don't know why it's taken us so long to figure that out because immune responses are energetically very costly. You know, there has to be sort of triaging of resources to be like, right, we're gonna fight this infection and turn on all the inflammation, turn on all the antibody producing and all those molecules that are being produced and the proliferation of, of immune cells. That takes a lot of resources.

    8. RCDr. Rangan Chatterjee1:07:17

       It does.

    9. SPSpeaker1:07:17

       So it needs energy, it needs building blocks.

    10. RCDr. Rangan Chatterjee1:07:20

        Is this why we feel tired when we're fighting an infection? Because the body's diverting resource-

    11. SPSpeaker1:07:25

        Yeah

    12. RCDr. Rangan Chatterjee1:07:26

        ... to making all that stuff that's gonna fight it.

    13. SPSpeaker1:07:28

        Exactly, and you might find that you need to kind of build yourself back up again after you've been, uh, sick, um, particularly if you've-

    14. RCDr. Rangan Chatterjee1:07:36

        Yeah

    15. SPSpeaker1:07:36

        ... been sick for quite a long time or if you have a ongoing illness. Your nutritional needs might be very different from somebody who doesn't have that. So im- immunometabolism is the field that's trying to understand how metabolism can shape immune responses and vice versa. So w- this happens at the level of the individual immune cell, but also can happen in the environment of a tissue and in the environment of our whole body. And this is something that there's not really any kind of absolute concrete, um- ... understanding yet in this area, but we know that when, uh, uh, a, an immune cell is fighting an infection, it goes through a metabolic switch and it goes from being in this kind of resting state to suddenly sucking up lots more, um, glucose to fuel, uh, proliferation. Th- the immune cells are making armies of themselves. Building antibodies requires, you know, the building blocks of proteins. All of this kind of thing is happening, and that metabolic switch is, is known as the Warburg effect. This is also what's happening to cancer cells. But immune cells do this when... and it's perfectly normal when they're fighting an infection or fighting any kind of, um, um, problem, and then it's switched back off and the immune cells go back to normal and they're, they don't have this huge need for metabolites anymore. But what people are starting to, to wonder is can the overall environment of a body influence, um, the, the metabolic switches inside our immune cells and switch them on aberrantly when they're not needed? So we know that, um, diabetics with poorly controlled blood sugar, so they have elevated blood sugar in, um, their body, this creates an environment that causes some of our immune cells like neutrophils to not work so well. So it affects... So immune cells have nutrient sensing, um, um, switches inside them, so they can sense what nutrients are in, a- are available, and they're taking in that information and then that affects how they can work. Now, what is not known is can we feed someone different, um, macronutrients, proteins, carbs or fats, and influence how their immune system is working? So can you switch unwanted immune responses off or on based on the different macronutrients that your body's metabolizing? And I think this is where the field of immunology is gonna be headed in terms of treating chronic diseases because we know that people with chronic diseases like metabolic syndrome, type 2 di- diabetes, heart disease, or people who are carrying too much visceral fat, that the whole environment of their bodies is metabolically different, and this might be causing the immune cells to act abnormally and be- become more pro-inflammatory, for example.

    16. RCDr. Rangan Chatterjee1:10:32

        Wow. Super interesting.

    17. SPSpeaker1:10:34

        Yeah.

    18. RCDr. Rangan Chatterjee1:10:34

        So a lot of research to come in that area.

    19. SPSpeaker1:10:36

        Exactly, and I think we just don't know enough-

    20. RCDr. Rangan Chatterjee1:10:38

        Yeah

    21. SPSpeaker1:10:38

        ... to say specifics yet, but I think that's, you know, for so long we've been focused on the micronutrients, but actually it's the macronutrients. So you could adjust someone's diet, give them different proportions of protein, fat and carb to maybe alter their metabolism and alter immune cells that were going wrong. So somebody who had a chronic infla- inflammatory disease, we could kind of steer that around. And-

    22. RCDr. Rangan Chatterjee1:11:02

        It's, um, incredibly exciting, isn't it?

    23. SPSpeaker1:11:05

        On the other side of it, l- what you said about eating less, um, another thing that I bring up in the book because I wanted to get people away from just thinking about, you know, a vitamin supplement for their immune system, is that the immune function is impacted by overnutrition and undernutrition. So if you're not eating enough or you're eating too much, this is gonna send your immune system awry, and I should context that by saying if you're doing that consistently. And then we have this field of research coming out about fasting and immune function. And I remember being at conferences decades ago, and they were talking about fasting and how it would regenerate, um, all sorts of parts of the body. It was kind of mind-blowing, and now we kind of see it more in the mainstream and we have all these kind of forms of different diets. Um, and this again is causing metabolic switches in the body that then when you go on to refeed after someone has had a period without food, you get an increase in, in growth hormone, you get production of fresh new immune cells from the bone marrow, um, and the stress of the lack of eating kind of causes some of the older immune cells and ones that might be more likely to malfunction to be deleted. So you're kind of replenishing your immune system, and we start to see in experimental models of autoimmune disease that this is, you know, highly therapeutic.

    24. RCDr. Rangan Chatterjee1:12:31

        Yeah, it's fascinating. The, it's not necessarily just what we're eating-

    25. SPSpeaker1:12:36

        Mm-hmm

    26. RCDr. Rangan Chatterjee1:12:36

        ... it's, you know, how much or how little. It's are we fasting, are we not fasting?

    27. SPSpeaker1:12:42

        Mm-hmm.

    28. RCDr. Rangan Chatterjee1:12:42

        All these kind of different components that-

    29. SPSpeaker1:12:45

        Yeah

    30. RCDr. Rangan Chatterjee1:12:45

        ... all play, I guess, they all play a role in the signals the body is receiving 'cause I guess that's all it is, isn't it?
11. 1:13:30 – 1:24:15

    Eating too often, postprandial inflammation and tuning into your own body

    1. SPSpeaker1:13:30

       And I think the thing with the, the sort of so-called Western diets that, that, y- you know, we talk about as being, having a negative impact on our health, um, it's just, it's just really tasty, and we just wanna eat it all the time. It's salty, it's sweet, it's delicious. It, it's everywhere. W- we can quickly override any lack of hunger cues just to, to, to eat. We kind of pathologize being hungry. It's like you're not ever allowed to be hungry.

    2. RCDr. Rangan Chatterjee1:13:58

       Yeah.

    3. SPSpeaker1:13:58

       You have to have 10 snacks in your bag in case you might not be able to reach some food. And, and then we have millions of incidences of eating across a huge portion of our, our waking time. And part of the research I was involved in several years ago was looking at postprandial inflammation. So when we eat, there's an inflammation, a subtle inflammation that happens in the body, and this is quite normal. We have plenty of checks and balances in place to keep that in check, and actually dietary fiber is one of the m- best ways to kind of seal that up again and prevent that from happening, as is having a period of, um, time without food in between meals. So eating enough and the right things at one meal that you do not need to eat then till the next meal, um, is actually quite good for over- overall-

    4. RCDr. Rangan Chatterjee1:14:43

       Yeah

    5. SPSpeaker1:14:43

       ... gut health, but the whole body health.

    6. RCDr. Rangan Chatterjee1:14:45

       I, I, I'm sort of super fascinated by this research as well and, you know- Not only do many of us eat too much, we eat too often-

    7. SPSpeaker1:14:54

       Mm-hmm

    8. RCDr. Rangan Chatterjee1:14:54

       ... in the day. And a- as you just said there, you know, the, the act of eating is inflammatory.

    9. SPSpeaker1:15:01

       Yeah.

    10. RCDr. Rangan Chatterjee1:15:01

        So that's a response to eating, is that your body will become inflamed. But as you say, nothing to worry about. It's sort of, that's part of-

    11. SPSpeaker1:15:09

        Yeah

    12. RCDr. Rangan Chatterjee1:15:09

        ... the process. But I guess, you know, and, you know, I know, uh, Satchin Panda's done a, a lot of look at this-

    13. SPSpeaker1:15:18

        Yes

    14. RCDr. Rangan Chatterjee1:15:18

        ... Professor Panda. Um, and I think when, when he started his app in 2015, I think it's called My Circadian Clock-

    15. SPSpeaker1:15:27

        Mm-hmm

    16. RCDr. Rangan Chatterjee1:15:27

        ... I, I, I can't remember the figures offhand, but it's something like 20, 30 years ago, most people were eating three times a day in the US.

    17. SPSpeaker1:15:35

        Mm-hmm. Yeah.

    18. RCDr. Rangan Chatterjee1:15:35

        I think we can probably infer in the UK as well. And then in 2015, when he was measuring-

    19. SPSpeaker1:15:41

        Mm-hmm

    20. RCDr. Rangan Chatterjee1:15:42

        ... and people were inputting into the app, I think the top 10% of people were eating 15 times a day, and it was a-

    21. SPSpeaker1:15:49

        Yeah

    22. RCDr. Rangan Chatterjee1:15:50

        ... you know, so that, if we think about that, let's say, let's say I'm eating 15 times a day, and let's say, in theory, it is all whole food, right? It's all nice, uh, health... W- what, what is considered-

    23. SPSpeaker1:16:04

        Yeah

    24. RCDr. Rangan Chatterjee1:16:05

        ... you know, you gotta be careful with the language, but what is considered sort of healthful-

    25. SPSpeaker1:16:08

        Yeah

    26. RCDr. Rangan Chatterjee1:16:09

        ... foods for our health. You do have to ask the question, is eating them 15 times a day healthful? That's, that's like 15 bouts of inflammation. Whereas if you had the same sort of food over, you know, it's, it's not a perfect analogy, but three times a day over five days, you're still getting 15 bouts of inflammation.

    27. SPSpeaker1:16:29

        Mm-hmm.

    28. RCDr. Rangan Chatterjee1:16:29

        But that's over the whole week-

    29. SPSpeaker1:16:31

        Yeah

    30. RCDr. Rangan Chatterjee1:16:31

        ... as opposed to in just one day. And I, I really do think societally, culturally, there's a problem with how much we're being encouraged to eat, even healthy foods.
12. 1:24:15 – 1:37:54

    Protein, fats and omega-3s in immunity

    1. RCDr. Rangan Chatterjee1:24:15

       Let's get into some more practical things. Um-

    2. SPSpeaker1:24:17

       Mm-hmm

    3. RCDr. Rangan Chatterjee1:24:17

       ... I think you, you've really helped people understand the immune system, how important it is.

    4. SPSpeaker1:24:22

       Mm-hmm.

    5. RCDr. Rangan Chatterjee1:24:23

       So food so far it's been potentially think about how often you're eating-

    6. SPSpeaker1:24:27

       Mm-hmm

    7. RCDr. Rangan Chatterjee1:24:28

       ... uh, how much you're eating, how you're eating-

    8. SPSpeaker1:24:30

       Yeah

    9. RCDr. Rangan Chatterjee1:24:30

       ... but also this diversity. You did mention saturated fats. Um, let's just quickly go through the macronutrients then, like-

    10. SPSpeaker1:24:38

        Yes

    11. RCDr. Rangan Chatterjee1:24:38

        ... 'cause there was a really nice bit in the book about protein and immunity, which I found-

    12. SPSpeaker1:24:41

        Yeah

    13. RCDr. Rangan Chatterjee1:24:41

        ... really interesting. Um, but saturated fat is, is a very hot topic of-

    14. SPSpeaker1:24:47

        Mm-hmm

    15. RCDr. Rangan Chatterjee1:24:47

        ... conversation in, uh, how can I put it? The Twitter diets wars.

    16. SPSpeaker1:24:51

        Yes. [laughs]

    17. RCDr. Rangan Chatterjee1:24:52

        Um-

    18. SPSpeaker1:24:53

        Definitely. You're clear of those. [laughs]

    19. RCDr. Rangan Chatterjee1:24:54

        Yeah, I, I, I do these days. I'm just like, "Okay, I'm, I'm over it, really."

    20. SPSpeaker1:24:57

        Yeah.

    21. RCDr. Rangan Chatterjee1:24:57

        I sort of, I don't find it particularly helpful. Um, but also when we talk about saturated fat, there's so many different types of saturated fat. It gets quite-

    22. SPSpeaker1:25:06

        Mm-hmm

    23. RCDr. Rangan Chatterjee1:25:06

        ... a nuanced discussion. But I wonder if you could, let's talk about protein, maybe we could-

    24. SPSpeaker1:25:10

        Mm-hmm

    25. RCDr. Rangan Chatterjee1:25:10

        ... talk about fats and carbs and actually-

    26. SPSpeaker1:25:12

        Yeah

    27. RCDr. Rangan Chatterjee1:25:12

        ... how you see them impacting the immune system.

    28. SPSpeaker1:25:15

        Exactly. So I think carbs is the quality and the quantity, so these are where we're getting the fiber to feed our microbiota. So, um, thinking of that diverse, colorful produce that we're trying to eat 30 different plant foods and over the course of a week. Um, carbohydrates are fueling our immune responses. Um, and then protein, I think protein malnutrition is probably globally one of the biggest factors that has a negative impact on our immune system because it's, it's... Protein breaks down into amino acids, and these are the building blocks to make so many other proteins in our bodies, and the immune system, i- is a huge sink for that because it needs, you know, antibodies are made from protein. The communication molecules are made from protein.

    29. RCDr. Rangan Chatterjee1:25:59

        So we need protein for the fabric-

    30. SPSpeaker1:26:02

        Yeah
13. 1:37:54 – 1:45:40

    Diet, depression and lifestyle psychiatry

    1. RCDr. Rangan Chatterjee1:37:54

       the conversation.

    2. SPSpeaker1:37:55

       The fact that poor diet is such a major issue globally for health really highlights the, um, the craziness of medical practitioners getting so little training on nutrition during their, during their, you know, uh, residencies, et cetera. It, it's a major issue. How much poor diet feeds into mental health problems is yet to be established, uh, and that's a really important question, but I suspect it varies enormously from individual to individual. And it should be always said that, uh, you know, something like depression is a very multifactorial disorder. There are so many things that drive into it, but if you think about the risk factors for mental illness, they're very often things that you can't readily change. They're things like family history, and early life trauma, and life events, and poverty, and disadvantage, and interpersonal violence. These are things that are often very challenging for societies to address. So we need to be looking for the things that we can modify, particularly if we wanna think about prevention, because half of all mental disorders start before the age of 14, so we want to be able to prevent as many cases as we can. So if we know that diet and physical activity are both modifiable risk factors for depression in particular, which we absolutely know from very extensive data from around the world, then this is where we should be targeting, um, our interventions as, as the low-hanging fruit

    3. RCDr. Rangan Chatterjee1:39:22

       Yeah, it, I have so many thoughts going through my head at the moment. You know, you mentioned diets and physical activity are modifiable risk factors for depression, but they're also modifiable risk factors for obesity. They're also modifiable risk factors for other conditions, which-

    4. SPSpeaker1:39:36

       Mm

    5. RCDr. Rangan Chatterjee1:39:36

       ... therefore in my head, you extend that thinking further and say, "Well, wh- well, how could these two things modify your risk of a whole variety of different conditions?" Maybe all the different conditions aren't quite as separate as we think they are. Maybe there is a common underlying driver, such as inflammation. [laughs]

    6. SPSpeaker1:39:56

       Yeah.

    7. RCDr. Rangan Chatterjee1:39:56

       No, I, I really think about this a lot. The more science that emerges in various fields of health and medicine, the more we often find that the lifestyle factors that we are promoting to help reduce the likelihood, or even help treat those conditions, are quite similar. [laughs]

    8. SPSpeaker1:40:14

       Absolutely, and I think this recognition of, um, certainly the common mental disorders such as depression as another of the chronic non-communicable diseases is a really important one because we certainly think, on the basis of the research, that they all have common drivers. But apart from anything else, it just makes so much sense to be tackling this, and I mean, we're really pushing for this lifestyle psychiatry or lifestyle medicine as a fundamental principle in psychiatry. Because if you think about depression, you think about how common it is, and recognize that if you are depressed, your risk for heart disease and obesity and a whole lot of metabolic problems goes right up. If you have those conditions, in turn your risk for depression goes right up. And then if you look at the serious mental illnesses such as psychosis and schizophrenia, we know that that patient group has a massively reduced lifespan compared to the general population because of their lifestyle behaviors and the impact of the drugs that they ha- are given. And we also know that if you tackle their lifestyle behaviors and support them to have a healthy diet and do exercise, it actually can mitigate nearly all of that, uh, noxious impact on their metabolic health. And then finally, if you go and look at the, um, the, the two intervention studies, the SMILES trial that we led and the one that, um, came after us in South Australia, where they did a detailed economic evaluation of both of them, and we showed that there was a massive cost saving because the people who, certainly in the SMILES trial, who got, uh, the dietary support compared to the social support, there was an average cost saving of about 3,000 Australian dollars. And that's because the participants lost less time out of role, and they saw health professionals less often. And the HealthyMed study in South Australia found very similar. So what it's saying is if you take this lifestyle medicine approach to supporting people with, uh, mental health problems, in this case depression, but it will also be the same in schizophrenia based on what we know so far, you're gonna get, uh, huge benefits across the board. It's not just targeting a particular molecule or particular, um, you know, brain pathway. It's, it, it's targeting the whole person.

    9. RCDr. Rangan Chatterjee1:42:29

       Yeah.

    10. SPSpeaker1:42:29

        And, and so it makes all sorts of sense. Now, in 2015, the updated clinical guidelines for the treatment of mood disorders were published in Australia by the Royal Australian New Zealand College of Psychiatry. I had quite a bit of impact, uh, input into that. And they said step zero, if you have a patient with, um, depression, step zero should be basically lifestyle medicine. It should be diet, exercise, sleep hygiene, smoking cessation, substance abuse.

    11. RCDr. Rangan Chatterjee1:42:55

        In, in 2015?

    12. SPSpeaker1:42:56

        That was in 2015. And the-

    13. RCDr. Rangan Chatterjee1:42:58

        So see, that has not been translated to clinical practice.

    14. SPSpeaker1:43:00

        No, that's right. That's right, and we really need to change the way we, we train practitioners. And I think, you know, obviously the pharmaceutical industry has had a big part to play in pushing a sort of a, you know, a pharmaceutical approach to treatment, and certainly this is not an either/or question.

    15. RCDr. Rangan Chatterjee1:43:17

        No.

    16. SPSpeaker1:43:17

        You know, we absolutely... Everyone in the SMILES trial was on... Well, most people were on other forms of treatment. But it's saying that this should be the starting point, the, the fundamental. And if clinicians take it seriously and they give diet and exercise advice as a prescription, and they say, "This is actually really important," we think that that will h- uh, help people to change their behaviors.

    17. RCDr. Rangan Chatterjee1:43:39

        Yeah, Felice, I think, in fact, that last point is something I keep trying to hammer home, um, when I'm talking to healthcare professionals and, and which is this whole point that, first of all, some people are very, uh, closed to the idea that food can make a difference in mental health. I was, um, giving a talk in Bristol for the Royal College of GPs to I think 100, 150 doctors there, and at the start I asked them, "How many of you will discuss a patient's nutrition or their, or their food in someone who comes in with a mental health problem?" And roughly 5% of the room put their hand up. This is only-- This is after the SMI- This was 2018, I think, actually. J- I think January, February 2018. And then I, I literally gave a 20-minute talk, just a, an overview of some of the research. Um, some of it I knew was yours, some of it I'd quoted of yours but I didn't realize it was yours. [laughs]

    18. SPSpeaker1:44:25

        [laughs]

    19. RCDr. Rangan Chatterjee1:44:26

        Um, and at the end of it I said, "How many of you are gonna do it now?" And they almost all put their hand up. And so it's really that slightly frustrating thing whereas there is research out there, guidelines are being written, but they're not being translated to clinical practice. And, um, this led me, a few years ago, with a colleague, create something called a Prescribing Lifestyle Medicine course that, you know, we're delighted the Royal College of GPs has accredited for the second year running. And we, we've trained I think about 1,000 clinicians now. Doctors, pharmacists, we've had a few psychiatrists, cardiologists, 'cause this is not just for a general practice problem, this is a problem across medicine. And again, we are n- we're not training them in nutrition, we're training them in a lifestyle medicine approach, how you evaluate a patient, how you can start to input various things from their symptoms a- and start to deliver a personalized lifestyle prescription. And, you know, 95% of attendees love it and say it's significantly influenced the way that they practice because we're not being given this information. And- I, I like you share that passion that lifestyle medicine, lifestyle psychiatry, these things-- You know, if you think about it, the l- the worst-case scenario here, worst-case scenario is that someone changes their diet, they, they don't feel any better. There's no downside, right?

    20. SPSpeaker1:45:38

        No. That's exactly right.

14. 1:45:40 – 2:00:07

    The SMILES trial: design, results and cost

    1. RCDr. Rangan Chatterjee1:45:40

       Well, let, let's dive into that research because I, I think the SMILES trial, which is... You know, I remember seeing that when it came out thinking, "Oh, my God, this is the first time that I had seen a randomized control trial showing how diet can improve symptoms of depression." You know, using the same level of evidence that we would expect from a phar- pharmaceutical drug, and that was the really exciting thing. Let's dive into what happened in that trial, why you thought of it, what the results were. But also, for, for the, for the members of the general public who are listening, um, nutritional research is quite complicated to do, isn't it?

    2. SPSpeaker1:46:14

       Yeah.

    3. RCDr. Rangan Chatterjee1:46:14

       And you've mentioned terms like observational studies, epidemiological studies-

    4. SPSpeaker1:46:19

       Mm

    5. RCDr. Rangan Chatterjee1:46:19

       ... intervention studies. Could you, could you just briefly explain what those are so people understand the difference?

    6. SPSpeaker1:46:23

       Yeah. And this is-- I, I have a chapter in the book that talks about this because it is so important that people understand this concept of, uh, the fact that correlation doesn't equal causation. And doing research in general is really difficult. Doing nutrition research is just horrendous. [laughs] But, um, so observational, uh, studies or also called epidemiological studies are where you collect lots and lots of information from people that you believe are representative of the population or representative of a, of a particular group of the population, and you use statistics to put those data together and to test hypotheses. Now, we led many, many studies in adults, including that first one, which was my PhD. Then we went on, and we looked in adolescents, a primary age of onset, really important to, to look at this in, in young people. Then in pregnant women and in children early in life, and then older adults, and we were joined by many other people from around the world. And from all of those observational studies, we can say that a adherence to a healthy diet seems to reduce the risk of depression by about thirty percent. But w- to know whether that is actually a causal relationship, whether diet is causing the mental health, you need to do experiments where you actually change diet to see if you can change mental health, and that's an intervention study. Now, the obvious problem with doing something like that in nutrition is that you can't blind people to the, to what they're getting.

    7. RCDr. Rangan Chatterjee1:47:52

       They know what they're eating.

    8. SPSpeaker1:47:53

       They know what they're eating. You can't have a placebo diet, you know? And there's no information to say that one particular form of healthy diet is better than another particular form. You can't ethically put one group of people on a junk food diet [laughs] and see what happens. So you've always got-

    9. RCDr. Rangan Chatterjee1:48:09

       Although Tim Spector did that to his son.

    10. SPSpeaker1:48:11

        Yeah. [laughs]

    11. RCDr. Rangan Chatterjee1:48:12

        You know, which is, which is actually episode one of this podcast. It was the very first conversation I had was with T-Tim, and he explained that he, that's exactly what he did to his son. Like any good research clinician would, scientist would do. But you're right, you can't ethically do that. [laughs]

    12. SPSpeaker1:48:24

        But so you, you have to do the best that you can, and you also have to, to triangulate the data. So you have to look at the human data, you look at the animal studies, and the animal studies are really useful because, of course, you can tightly control diet, and then you can chop their heads off at the end and see what's going on in the brain and that sort of thing. But with the human, uh, data, I, I designed it when I was a very early postdoc, the SMILES trial, and, um, it took me a couple of years to get funding for it. But we got the funding, but they slashed the budget by thirty-five percent, so we really did it on the smell of an oily rag. You know, it was a really, really difficult and challenging study to do. We really struggled to recruit people, and I think-

    13. RCDr. Rangan Chatterjee1:49:03

        Really?

    14. SPSpeaker1:49:03

        Yeah. This is really interesting because we, we had hoped to recruit about a hundred and eighty patients with major depressive disorder. After three and a half very long, hard years, we'd recruited sixty-seven. Now, I think that's for two reasons. One is that people in general were skeptical that diet was gonna have an impact on something as serious as major depressive disorder. But really importantly, clinicians, they were just completely skeptical, so none of them sent their patients to us to enroll in the trial. So that was really challenging. Um, but what we did in that study was we, we recruited people with major clinical depression, and we randomly assigned them to get either social support or dietary support for a period of three months. Now, the social support, we already know that that's helpful for people with depression.

    15. RCDr. Rangan Chatterjee1:49:49

        Yeah.

    16. SPSpeaker1:49:49

        That's just going and talking to someone. You could be talking about the football or your grandchildren or whatever, but it, we know that it's helpful, and it's called a befriending protocol. They often use it in psychotherapy trials as a control condition. And then the other g- groups saw a clinical dietitian for three months, and that dietitian just worked with those people to help them to gradually make positive changes to their diet, to set some goals, to do it in a way that was feasible and achievable for them. And that was things like swapping out their, you know, refined carbs, their white flour, white bread, et cetera, for whole grain versions, increasing the amount of vegetables and fruit in their diet, starting to eat more legumes, so your lentils and chickpeas, et cetera, having some nuts and seeds, eating fish, getting some olive oil into their diet, but also, really importantly, reducing the intake of, you know, the junk and processed foods, the sweets and cakes and chocolate and fried foods over a three-month period. And at the end of the study, because we only had sixty-seven people, we had no expectation whatsoever that we would see a significant difference between the groups on the depression outcomes. We just thought it was incredibly unlikely. And I sat with the statistician, and we did the stats, or she did the stats, and it was... You know, you don't unblind the groups until the end. We just knew it was group A and group B. And there was just this massive difference in the depression scores after three months, and we were just completely blown away.

    17. RCDr. Rangan Chatterjee1:51:15

        How, how big a difference?

    18. SPSpeaker1:51:17

        Well, h- to put it into a, I, I guess a, a meaningful context, more than thirty percent of the people in the dietary group achieved what we would call full remission, where they just weren't depressed at all anymore, and that was compared to about eight percent in the social support group.

    19. RCDr. Rangan Chatterjee1:51:31

        So hold on. That-- We, we just gotta pause there because, you know, I'm asking you the question for the listener. I'm, I'm very familiar with the trial. Um- That is absolutely remarkable. You, you were talking about people who have got moderate or severe depression-

    20. SPSpeaker1:51:46

        Mm-hmm

    21. RCDr. Rangan Chatterjee1:51:46

        ... who literally were, were, they were doing exactly what they were doing. If they were on treatment, I believe they stayed, they were already-

    22. SPSpeaker1:51:53

        Yes, that's right

    23. RCDr. Rangan Chatterjee1:51:53

        ... they were staying on everything they were doing-

    24. SPSpeaker1:51:54

        Mm-hmm

    25. RCDr. Rangan Chatterjee1:51:54

        ... but they were just split into two groups, and if you change your diet, within 12 weeks you got above a 30% remission rate in symptoms-

    26. SPSpeaker1:52:01

        Mm

    27. RCDr. Rangan Chatterjee1:52:01

        ... of depression. That is absolutely staggering. No wonder s- you got so much attention-

    28. SPSpeaker1:52:07

        Mm

    29. RCDr. Rangan Chatterjee1:52:08

        ... after that trial because not only are the results amazing, the fact that you, everything you had to overcome, the skepticism, recruiting patients, all this kind of stuff, you know, and you didn't know it till the end. I mean, do you remember where you were when... Do you remember-

    30. SPSpeaker1:52:22

        Oh, absolutely
15. 2:00:07 – 2:12:06

    Mediterranean diet, red meat and the gut microbiome

    1. RCDr. Rangan Chatterjee2:00:07

       I... I, I really wanna go into the, the foods that were in the SMILES trial. What foods were these participants given, and then why do you think that these foods had an impact on moods?

    2. SPSpeaker2:00:22

       Great question that we don't have the answers for. So, uh, we based the dietary advice on, um, the best science available, and that, of course, the, the Mediterranean diet has the s- by far the strongest and the largest evidence base.

    3. RCDr. Rangan Chatterjee2:00:35

       And what do you mean by a Mediterranean diet?

    4. SPSpeaker2:00:37

       Yeah, I know.

    5. RCDr. Rangan Chatterjee2:00:37

       'Cause a lot of people then say-

    6. SPSpeaker2:00:38

       There's many [laughs]

    7. RCDr. Rangan Chatterjee2:00:39

       ... you know.

    8. SPSpeaker2:00:39

       And, and it, this is not a prescriptive diet, but it's basically a diet that is, um, much higher in plant food, so vegetables and fruits, um, legumes, uh, that's your lentils and chickpeas, et cetera, nuts and seeds. So all these sources of dietary fiber, and we can talk about why that-

    9. RCDr. Rangan Chatterjee2:00:58

       Sure

    10. SPSpeaker2:00:58

        ... we think that is particularly important in a little while. But also healthy fats, so these are the mono and the polyunsaturated fats from fish and olive oil, et cetera. You know, healthful forms of protein. But we also included recommendations for, um, three or four, uh, palm-sized servings of unprocessed meat per week, which is at odds with the traditional Mediterranean diet, and that was on the basis of, um, a study that I'd published where I saw very unexpectedly a very clear U-shaped relationship between red meat intake and, um, depressive and anxiety disorders and even bipolar disorders in this large population-based sample of women. So women who had less than the recommended intake, which is this three to f- uh, four small serves a week, or more than the recommended intake, when we took into account their overall diet quality, they were twice as likely to have a clinical depressive or anxiety disorder.

    11. RCDr. Rangan Chatterjee2:01:55

        Okay, I mean, this is, this is super fascinating, especially with the growing movement to move to vegan diets-

    12. SPSpeaker2:02:02

        Mm

    13. RCDr. Rangan Chatterjee2:02:02

        ... um, which is, you know, exploding really around the world in terms of popularity. A lot of people are doing it for, um, ethical reasons.

    14. SPSpeaker2:02:10

        Mm-hmm.

    15. RCDr. Rangan Chatterjee2:02:10

        Um, and there's a lot of, uh, as you well know, a lot of controversy in what I call the, the social media diets wars. Uh, it really-

    16. SPSpeaker2:02:18

        Yeah, [laughs] I call it that too. [laughs]

    17. RCDr. Rangan Chatterjee2:02:19

        It really highlights how, um, how complex nutritional research is, because people seem to have the same paper, and there's five different interpretations, and then people write their blogs about them, and then Joe Public is like, "Well, what the hell do I do?"

    18. SPSpeaker2:02:32

        [laughs]

    19. RCDr. Rangan Chatterjee2:02:32

        "Because I, this expert who I respect is saying this, this expert who I respect is saying the complete opposite." And I think that, that confusion is causing big problems with patients. I s- I see that all the time.

    20. SPSpeaker2:02:42

        Mm.

    21. RCDr. Rangan Chatterjee2:02:42

        They're just confused.

    22. SPSpeaker2:02:42

        And with doctors as well.

    23. RCDr. Rangan Chatterjee2:02:43

        And with doctors, exactly.

    24. SPSpeaker2:02:44

        [laughs]

    25. RCDr. Rangan Chatterjee2:02:44

        And, you know, I, I'm sort of trying to keep on top of the research, and even I get confused sometimes. I think, "Well, hold on a minute. I thought that, and then now this trial is suggesting that." And it's--

    26. SPSpeaker2:02:53

        Mm.

    27. RCDr. Rangan Chatterjee2:02:53

        You've gotta take that balanced approach. But let, let's dive into some of these foods. So red meat, right?

    28. SPSpeaker2:02:58

        Mm.

    29. RCDr. Rangan Chatterjee2:02:59

        Is red meat, from what you have seen ... I mean, I, I mean, that's an overly simplistic question. I, I'm sort of, uh, I'm trying, I'm trying to bring out basically, do you think red meat is good for our mental health?

    30. SPSpeaker2:03:10

        I have no particular opinion on it. I think our study was a really unexpected finding. It was a very clear finding, and it's sort of concordant with other epidemiological studies where you see a link between vegetarianism and poor mental health. But we just don't know whether it's a causal relationship. It could well be explained by third factors that we haven't measured or haven't accounted for. So I would not hang my hat on that. I do hear a lot of clinicians saying that they quite commonly will see young women who are menstruating, who are vegetarian, and they're really in a terrible state, and they have, um, they get a lot better when they reintroduce red meat into their diet.

Episode duration: 2:12:06