The DAILY HACKS To Heal The Body & Mind WITHOUT MEDICATION | Dr. Ayan Panja

Dr. Rangan Chatterjee 0:00 You've been seeing patients now for almost 25 years. You've seen tens of thousands of patients, and I think you're very, very good at helping your patients help themselves. You've got all kinds of techniques to help people with things related to autoimmune disease, type 2 diabetes, depression, anxiety. Whatever it might be, you've got tools and techniques to help. So I wanted to start off by asking you, with all that experience, what are some of your top practical tips that you keep coming back to time and time again because you know that they work?

Dr. Ayan Panja 0:40 Okay. So the first one, which I do myself, um, and it may seem innocuous, is something called a one-minute recharge. So this is something that combats stress, and it's very simple. All you do is for one minute, you literally just do nothing. So I do this when I pull into work in my car. I, I used to put a minute timer on my phone, and I just close my eyes and just sit and breathe slowly and think of something that makes me feel relaxed. It's often lying on a beach for me, and if you really heighten the experience, you can sort of feel the heat of the sun on your face. You know, the brain's so powerful, and when the alarm used to go off after that minute, I used to want that minute to just go on and on. But what it does is it means that whatever stresses I have in the day, I'm much better able to handle them having done that one minute of just activating my vagus nerve, whatever you wanna call it, whatever's going on physiologically. And I do the same when I pull into the drive at home so that I can sort of metaphorically leave the doctor's bag outside the door. Sounds ridiculous, but it works, and the last time I recommended this was on someone who is a hospital doctor, has got a very stressful job, and I got a text from them saying, "Do you know what? It's ridiculous, but it actually works." You know, and they, they... It's, it's two minutes a day, so however busy you are, if you can afford two minutes just to do that and you don't have time for yoga, meditation, all of those things that we know are good for you but actually require a bit of time, if you don't have that time, just do the one-minute recharge twice a day.

Dr. Rangan Chatterjee 2:29 So you don't do it first thing in the morning. You do this once you've, you know, got your kids off to school, you've done what you need to do at home, you, you've driven to work. You've done it at that point before you go into work. Why do you do it then?

Dr. Ayan Panja 2:42 Yeah, because, you know, we're always sort of on go, and the, the, the natural instinct is when you rock up to work is to just rush in through the door. But the nature of my work is such that, and, and like a lot of other people, is that you're just slammed with problems the minute you walk into the building, and if you're on a sort of... If you're in a state of, you know, of fight or flight or you- you're rushing around and your heart rate's up, then that will just, you know, that stress that you're being hit with will just sort of exacerbate how you're feeling, whereas if you're calm to start with, your ability to handle those things, mine certainly, is better. 'Cause the days I don't do it, which is rare, but occasionally I forget because I'm just late or something, I really notice it. You know-

Dr. Rangan Chatterjee 3:32 Mm

Dr. Ayan Panja 3:32 ... things irritate me a little bit more or my patience isn't quite the same, and it's the same at home. You know, y- y- you get home at the end of a, a long day, and it's suddenly like the washing machine's broken down again or whatever. Something else has happened, and those things stress you less. It's just a, it's a very simple practice that pays a lot of dividends. You know, it's, it's two minutes a day.

Dr. Rangan Chatterjee 3:54 Yeah. I- it's interesting that the hospital consultant who you recommended this to was skeptical.

Dr. Ayan Panja 4:00 Mm.

Dr. Rangan Chatterjee 4:01 And I think there's probably people listening or, or, or watching right now who are... You know, they, they share that skepticism. Like, what is that really going to do for me? I think you've explained just how powerful it is for you. For that person who's skeptical-

Dr. Ayan Panja 4:19 Mm

Dr. Rangan Chatterjee 4:20 ... just talk me through or explain it as if you were explaining it to a patient, you know, what would they do? Right, let's say they, like you, are driving to work.

Dr. Ayan Panja 4:29 Mm.

Dr. Rangan Chatterjee 4:30 You know, what are they doing? Is it... Y- you mentioned silence. A lot of people don't know how to sit in silence.

Dr. Ayan Panja 4:37 Mm.

Dr. Rangan Chatterjee 4:37 Right? Their, their, their mind starts rushing, you know. So what about music? What about a guided meditation? You know, um, you know, help us understand how exactly you do that.

Dr. Ayan Panja 4:47 Yeah. Yeah, so, so those things, like guided meditation or music, they're, they're absolutely fine. Um, and I think the reason I wanted to do silence is that it, it, it's a total switch off. So you're right, some people find it very difficult, and actually, when I go and do talks on wellbeing or, you know, kind of... Companies sometimes ask me to come and talk to their staff. Um, I o- I often start with this, and I go, "I just want you to just sit quietly in, in your chairs for a minute, and I'm gonna do it with you. I want you to close your eyes for a minute." And then once we've done the minute, what I, what I do is I go, "How many of you found that easy?" Not many hands go up.

Dr. Rangan Chatterjee 5:27 Mm-hmm.

Dr. Ayan Panja 5:27 And then I go, "How many of you wanted that minute to go on for longer?" It's the same sort of number of people. And I go, "How many of you found that difficult to do?" And then loads of hands go up because invariably, wherever I've gone to do the talk, you know, whether it's like a, a police force or s- whatever, they work in a very high pressured sector, so they're always on go. But actually, the more you do it, the more you get used to sitting with that stillness, and i- if you're finding it difficult and you've got worries coming into your head, one of the things I tend to do is I use the breath, you know, and I go, "If you've got a worry coming into your head, just stop. Go back to the beginning of a breath and think of something that makes you feel relaxed." Some people find it hard to find something to think about that makes them feel relaxed. It just shows you the kind of world we, we live in. And I, I picked that stereotype, one of the beach, 'cause that does make me feel relaxed.

Dr. Rangan Chatterjee 6:20 Yeah.

Dr. Ayan Panja 6:20 But, you know, the, it's whatever works for you.

Dr. Rangan Chatterjee 6:22 And I think there's a key point there that if you never expose yourself to silence, you may well find it hard at first, right? So it, it doesn't mean that the practice is not for you. It just means that you need to bear with it and, and practice and keep doing it. And what I love about it is that it is so simple, right? It doesn't take long time-wise. It doesn't cost any money. So it's something that pretty much everyone can introduce. You know, I, I can imagine that as a doctor, doing that before you start seeing your patients is gonna make you more present and more attentive and, you know, better able to be the doctor that you want to be. I think that applies to all of us in our own lives. I think there's also something really powerful, though, about what you said. You do it when you're sitting in your drive after your long day at work, before you go into your house. And I know you're married, you've got your kids. I think that's another really important time of the day, where if we don't do something, you know, if we carry that stress-

Dr. Ayan Panja 7:29 Mm

Dr. Rangan Chatterjee 7:29 ... into our homes, it affects our relationships, right? It affects all kinds of different things. So maybe talk to me about, you know, why it's so important for you to do it at that time of day, and what you found with your patients when you introduced this idea to them as well.

Dr. Ayan Panja 7:44 Yeah. I... It, it's interesting. So for me, it's because, again, the nature of the, the job that I do means it's very easy to sort of take it into the house with you, you know, mentally. And also, um, you know, my, my wife's a doctor, and so she has a similar sort of stress. We don't sort of tend to talk shop, but it's nice to kind of leave it metaphorically-

Dr. Rangan Chatterjee 8:07 Mm

Dr. Ayan Panja 8:07 ... outside so that you can be present and do the things that you would do in family time. Um, it's interesting what you say about patients. One of them, um, actually found that rather than doing that, it sort of worked to a point, that what helped them was getting changed into a tracksuit. You know, changing, changing clothes-

Dr. Rangan Chatterjee 8:28 Mm

Dr. Ayan Panja 8:28 ... seemed to be the thing for them. Whereas doesn't really make, make any difference for me. I tend to wear [laughs] the same things at home and work nowadays. You know, post-COVID, I sort of don't look quite as smart as I used to ma- many years ago at work. But, um, so s- so it's whatever works for you. That one really works for me because it, it, it has this calming effect, um, on me, and it means that... In, in a way, I guess what I'm doing subconsciously is kind of allowing all the kind of stresses of the day to just sort of stop right there, and then I pick them up again when I sort of head out the house the next morning. You know, that that's what's-

Dr. Rangan Chatterjee 9:04 Mm

Dr. Ayan Panja 9:04 ... going on at the back of my mind, I guess, so.

Dr. Rangan Chatterjee 9:07 Yeah, I, I, I love that about the patients changing their clothes.

Dr. Ayan Panja 9:11 Mm.

Dr. Rangan Chatterjee 9:11 I mean, I call these things transition zones in the day, and I think they're really, really important if we-

Dr. Ayan Panja 9:17 That's exactly it, yeah

Dr. Rangan Chatterjee 9:18 ... you know, we pay attention to them. Just some way to kind of shift your state, right? So as you say, it could be that mindful minute or it could be changing your clothes, whatever it might be. For me, changing clothes is a big one when coming in. Um, okay, so that's one of your-

Dr. Ayan Panja 9:32 Mm-hmm

Dr. Rangan Chatterjee 9:32 ... kind of tried and tested-

Dr. Ayan Panja 9:34 Yeah

Dr. Rangan Chatterjee 9:34 ... tips, hacks if you will, that you found beneficial yourself and with many patients.

Dr. Ayan Panja 9:40 Mm, mm.

Dr. Rangan Chatterjee 9:40 Any others?

Dr. Ayan Panja 9:41 Yeah. The next one is a really simple one, and it is... It's, it's hydration actually [laughs] . Talking of which. Mm. And it's one that I've noticed in retrospect. And a lot of the things in, in the book you'll notice are just from myself learning from patients and my own experience and also matching it with evidence. And as junior doctors, I, I remember thinking actively, "Wait a second, you know, my patients are all on more fluids than I get through in a day." And I'd literally have this, like, can of fizzy drink in my white coat when you were still allowed to wear them, and that handbook that all junior doctors [laughs] have in the other pocket. And then I'd just... I'd get through one a day, and I'd just be exhausted because we worked so many hours. But it's the same principle in, in kind of grown-up doctor life as well, and, and for, and for many of my patients where, you know... And the thing that... The last time I remember sort of recommending this was someone who had really poor concentration, actually. It was a, a guy doing his A levels, and just had come with, with a, with his mother, and the story was that, you know, he just can't focus, can't concentrate, whatever. But relatively healthy, very sort of sporty, which in a way meant that, you know, obviously being sporty you sweat a lot more.

Dr. Rangan Chatterjee 10:57 Mm-hmm.

Dr. Ayan Panja 10:57 But, uh, drilling down into sort of that, that guy's routine, you know, they just didn't drink. And it's like, "Well, I just, I never feel thirsty." And I'm like, "Wait a minute." But, you know, then literally he'd have, like, one drink in the morning, and that would be it till the end of the day. And the change in him, you know, just in t- I didn't sort of follow him up in person, but just, you know, often d- we do things by text message or on the phone a lot more these days, was just dramatic. He was just like a new person, and that is just by making sure that you're drinking enough water in the day. It... You know, the, the benefits of hydration, you know, you can... It's, it's one of these ones that's safe to Google, I think, you know? Are just ridiculous, you know, just in terms of skin, brain function, um, renal function, just, just everything about your health, unless you've been advised not to. Some people have to fluid restrict, but that's when they've got particular medical conditions. It is just one of the things that I, I cannot highly recommend enough. So one of the things in the book actually in terms of, which we'll probably come onto in terms of morning routine, is drink a glass of water. And a lot of people looking at that will go, "Well, where's the science behind that?" It's... There's no real science. It just gets you, your hydration process for the day kickstarted. Simple as that.

Dr. Rangan Chatterjee 12:11 Yeah. Completely concur. Uh, the amount of people who don't drink enough is huge.

Dr. Ayan Panja 12:17 Mm.

Dr. Rangan Chatterjee 12:18 And, you know, all kinds of things are often related, aren't they? Low energy, often, not always, of course, but often-

Dr. Ayan Panja 12:26 Yeah

Dr. Rangan Chatterjee 12:26 ... you're just not drinking enough water.

Dr. Ayan Panja 12:28 Yeah.

Dr. Rangan Chatterjee 12:28 And it can be transformative. Headaches sometimes related to dehydration. Stomachache. You know, it's so common, and as you say, it's one of those things that, you know, is very safe to recommend-

Dr. Ayan Panja 12:40 Mm

Dr. Rangan Chatterjee 12:41 ... um, and it has potential multiple downstream benefits.

Dr. Ayan Panja 12:45 Yeah.

Dr. Rangan Chatterjee 12:46 Okay. I like those. Two very, very simple tips that can have, you know, huge-

Dr. Ayan Panja 12:51 Mm

Dr. Rangan Chatterjee 12:51 ... implications for people. Uh, before we get into the book, third one perhaps?

Dr. Ayan Panja 12:56 Okay. Third one's one I struggle with myself, which is to do with sleep, and my problem is I get to bed too late, um, which in itself is a problem. So for me, I want to kind of get to bed a bit earlier. But the tip that I would give is to try to get to bed at the same time each night and get up at the same time each morning, and the reason for that is to do with your circadian rhythm and the fact that even though you think, and I do this myself, where you think, oh, I'll have a lie-in, you know, on a Saturday or a Sunday, you're actually messing up your circadian rhythm, which in a, in a way will, as, as you know, you know, some people call it the rhythm of life, um, messes everything else up in terms of blood sugar control-

Dr. Rangan Chatterjee 13:41 Mm

Dr. Ayan Panja 13:41 ... your cravings, your mood, your stress levels. And when I can do it well for a few weeks, the difference in how I feel, you know, my energy levels, my brain power, my stress levels, everything improves. Um, and you know, as we c- come onto what's in the book, you know, as, as you know more than anyone else, you know, all of this stuff is interconnected. But sleep, I think, is probably the most underrated function. We take it for granted, don't we? Because it's just something we all do, you know? Um, but it's so important to prioritize it, and I think that's hitting me more and more the older I get.

Dr. Rangan Chatterjee 14:17 Yeah. What, what in your experience is the main obstacle for people in terms of getting good quality sleep?

Dr. Ayan Panja 14:26 Um, it, it, it really varies, 'cause insomnia, you know, if we, if we call it that, um, that we see in practice, has lots of root causes, and a lot... I, I do find a lot of people have done the basics. So they go, "Well, I've cut caffeine out, you know, and I'm, I'm trying not to kind of..." And they've done a lot of reading. They go, "I'm trying not to look at blue light," and all the, all the sort of things that you would see in terms of simple advice, but they still struggle. And I think m- my analysis is that people are just wired and tired. They've got too much on their plates, you know. They can never switch off. Um, you know, we're living through difficult times anyway, where people have just got a lot on their minds, you know-

Dr. Rangan Chatterjee 15:04 Mm

Dr. Ayan Panja 15:04 ... whether it's just from what they watch on the news or whether it's what's going on in their own lives. And, and, and often it's just, you know, there's n- there aren't enough hours in the day for a lot of people I know to, to do what they've got to do-

Dr. Rangan Chatterjee 15:16 Yeah

Dr. Ayan Panja 15:16 ... whether it's work or whatever, so they're not getting that ability to switch off. And again, you know, going back to the first tip, that sort of one-minute recharge, you asked me a minute ago whether I do that first thing in the morning. Um, I don't actually, but some people would benefit from doing it then or last thing at night. If you're someone who's a perfectionist and you just worry all the time about things, one of the exercises, again, I mention it in the book, one of my patients taught me this, is that he actually sort of makes sure that... He's, he's very perfectionist, and he's got a perfectionist type of job, uh, in, in engineering, and so he sort of has to make sure that everything is sort of at peace, you know, as in, "I'm not gonna worry about that," before he goes to bed. And, and actually, that one-minute recharge kind of thing mi- might help there. But, um, so it d- depends how you're wired in a way.

Dr. Rangan Chatterjee 16:07 Yeah. Certainly for me, what I've seen with people and I've experienced myself is that, you know, that one-hour period before bed is so, so important, you know. What signal are you giving your body and brain? And I always use the analogy about children. You know, when we've got kids that we wanna get to bed, we create a certain environment to assist that. You know, we, you know, we don't give them a ton of sugar. We don't have their music blaring. We don't have bright lights on. No, we kind of do the opposite, don't we? We calm everything down. We soften. We, you know, if there's music playing, it'll be soft music. We, we read them stories. And the older I get, the more I realize that adults are just not that different from kids. We also need a signal to us that, oh, it's the end of the workday. It's the end of daytime. It's now nighttime. And I think these lack of boundaries we now have, because you can check your work email on your phone that you might have next to you whilst you're watching TV in the evening, well, you know, at 9:00 PM, suddenly you are looking at that work email, because it's easy to do that. So I know for me, I have to have... Not I have to have, I choose to have a one-hour, you know, a routine sounds as though it's kind of really disciplined and drilled. It's not. But in that one hour before bed, I pretty much switch the laptop off. I won't look at work emails. I'll try as much as possible that things are, um, relaxed and soft. And I'm pretty good these days at not going and doing work even if it needs to be done. I appreciate, you know, everyone's got different requirements with their work, and sometimes they just have to do it. I, I do get that. But I know for me that having that one hour where I pretty much don't do anything stimulating for my mind, it makes every hour of the following day better ... you know, more productive, more, uh, empathy, uh, better food choices, um, better relationships. Do you know what I mean?

Dr. Ayan Panja 18:24 Mm.

Dr. Rangan Chatterjee 18:24 So I, for me at least, I have structured my life in such a way that I can have that one hour before bed where I'm not doing work stuff. There's something you find tricky with your job, isn't it?

Dr. Ayan Panja 18:37 It is, yeah, and I, I know it's something I've got to address and, and c- certain days in the week it's easier than others, but three days a week it's pretty much impossible, you know, just 'cause, uh, just because of the working week. Um, so-

Dr. Rangan Chatterjee 18:50 Well, well why don't you paint a picture of that? 'Cause I think a lot of people don't realize what, you know, a f- a kind of full-on NHS GP, what does that day look like?

Dr. Ayan Panja 19:01 Yeah. It, it's, [laughs] it just, you never stop, you know? And, and I guess, you know, it starts early. It depends what time you get in. I, I actually sort of go in... Nowadays, I go in a little bit later, by half 8:00, but I... That's unusual. A lot of people, a lot of my colleagues are in at half 7:00, you know? And that, but the, the downside to me going in late means I get away late because I have more work left. And so, and what's changed while we're on NHS general practice is that you used to sort of ring up, get an appointment after a few days, and, you know, you'd come in with all sorts of things. Sometimes it's minor illness, sometimes it's something complicated. Nowadays, nearly everything is complicated. So we've got all the minor illness, and I say minor illness 'cause it's only minor in retrospect, you know, ear infections, chest infections, urine infections, coughs and colds, all that stuff, and we've got, you know, brilliant paramedic team at work who cover almost all of that. But the volume of complex stuff, and I, I'm making these up, but the kind of thing that you'll see, you know, you, you'll come in in the morning and there'll be 60 names on the list, and the first one might be 11-year-old who, you know, has locked themselves in the bathroom and won't come out, and the family only want to speak to a particular doctor 'cause they know them. Really complex problems. You can't just toss this to someone else 'cause there's no resource in... You know, hospitals are slammed, community services are slammed. The second one might be an elderly gentleman who's, you know, um, rung, uh, the paramedics, and the paramedics aren't quite sure whether to take them into hospital and want the GP to review. Again, not something you can do in 10 minutes very easily-

Dr. Rangan Chatterjee 20:41 Mm

Dr. Ayan Panja 20:41 ... 'cause normally they've got very complex needs. Another one might be someone who's suicidal. You know, again, not something easy to, to handle, and again, there's no, there's nowhere to sort of... You can't just send these people to places, you know, easily 'cause the resource isn't there. So we end up holding a lot more risk, um, and of c- and of course the patient, you know, is, is in dire need. So, you know, and they struggle to get through anyway because there are less GPs nowadays.

Dr. Rangan Chatterjee 21:11 Mm.

Dr. Ayan Panja 21:11 So there's less of us in the system. So that, it's a perfect storm. People are more ill with more complex stuff, and there are less of us. I mean, it's just... And you know how the story might end there because it's just, you know, there'll be n- there'll be n- nothing in the end if we don't... I don't know what the answer is. I'm not gonna get political, but you know, we, we, we just need to be aware that that's going on.

Dr. Rangan Chatterjee 21:33 Yeah. I, I, I genuinely feel that a lot of the public don't realize what GPs actually end up seeing, and that the clinic times are just one aspect of the work.

Dr. Ayan Panja 21:47 Mm.

Dr. Rangan Chatterjee 21:47 And I understand that there's huge amounts of frustration-

Dr. Ayan Panja 21:51 Mm

Dr. Rangan Chatterjee 21:51 ... that people can't get appointments.

Dr. Ayan Panja 21:52 Mm.

Dr. Rangan Chatterjee 21:52 I think-

Dr. Ayan Panja 21:53 Absolutely. Mm

Dr. Rangan Chatterjee 21:54 ... it's, you know, obviously it would be ideal if everyone who wanted an appointment got one when they wanted to.

Dr. Ayan Panja 22:02 Mm.

Dr. Rangan Chatterjee 22:02 But as I've mentioned many times [laughs] on the podcast before, I don't know a single GP who works in the NHS who is not overworked, probably close to burnout in some way, and the workload, the stress is impacting, you know, their personal life, their relationships, the amount of time they have with their family.

Dr. Ayan Panja 22:25 Mm.

Dr. Rangan Chatterjee 22:25 And again, I understand that it's not just unique to GPs or doctors.

Dr. Ayan Panja 22:29 Mm. Mm.

Dr. Rangan Chatterjee 22:29 There are loads of professions who are in this boat as well, you know?

Dr. Ayan Panja 22:33 Yeah.

Dr. Rangan Chatterjee 22:34 Teachers, nurses-

Dr. Ayan Panja 22:35 Mm

Dr. Rangan Chatterjee 22:35 ... uh, just to, to name just a few.

Dr. Ayan Panja 22:38 Yeah.

Dr. Rangan Chatterjee 22:38 How frustrating is it for you when there are, uh, negative headlines about GPs, and there's that whole narrative of, "Oh, they're just lazy. They're not seeing enough patients"?

Dr. Ayan Panja 22:50 Mm.

Dr. Rangan Chatterjee 22:50 You know, what, what does that feel like for you?

Dr. Ayan Panja 22:52 Yeah. All of us want to do a good job, but we are under-resourced, and it's, it, it's very, very disheartening because you're doing your best in, in really, really difficult circumstances. It's interesting actually. I went to my mum's GP surgery the other day, which is down the road from where I work, and I went to pick something up, a form, and, um, I was having a chat to the reception, um, m- team member there. And what's, what, the, the, what's interesting is when you walk into the building, 'cause it's relatively empty, you think, "There's no one here." You know, you're not d- how, how come it's so busy? How come we can't get through? And the stress, of course, is what I just told you about the 60 names on that list, that yeah, they're names on a screen, but they're really complex problems, you know? And if you suddenly sort of put those names on a screen in the context of an A&E department where everyone's got scrubs and there's beeping machines and stuff and, and more serious stuff going on behind the curtains like heart attacks and, you know, stuff that goes on in resus, it, it suddenly seems more serious 'cause you're in that setting.

Dr. Rangan Chatterjee 23:59 Mm.

Dr. Ayan Panja 23:59 And because primary care is a bit more close to home, and when, when you see that, you know, the waiting room's not full, you just assume that there's, there's not much going on. But actually, you know, behind those closed doors, you've got a battered GP who's just got, you know, 100 very complex problems to solve in a day.

Dr. Rangan Chatterjee 24:20 Mm.

Dr. Ayan Panja 24:20 I, I, I, I've said this before, but- I was trying to explain to someone the other day that, um, sometimes, you know, I've had, not, not recently, but I've had up to 100 letters to read in a day in terms of stuff that comes back from the hospital. Each one will have an action for me. The ones that don't have an action just get filed into the patient's notes. And then, then you've got an action like, "Please tell the patient to go and do this," or, "Please can you arrange this?" I mean-

Dr. Rangan Chatterjee 24:47 But, but, but also the implication-

Dr. Ayan Panja 24:49 Of not doing it

Dr. Rangan Chatterjee 24:49 ... of missing something.

Dr. Ayan Panja 24:51 Yeah, exactly. Yeah.

Dr. Rangan Chatterjee 24:52 You know, that's, that's the thing, isn't it? You talk about those names-

Dr. Ayan Panja 24:56 Mm

Dr. Rangan Chatterjee 24:56 ... and the, the, the wide variety of things that can be on that list.

Dr. Ayan Panja 25:01 Mm.

Dr. Rangan Chatterjee 25:01 Just take one, that person who's suicidal.

Dr. Ayan Panja 25:03 Mm.

Dr. Rangan Chatterjee 25:04 We all know what that's like when you then have to deal with that, and, um, almost everything else becomes secondary 'cause you're trying [laughs] to deal with-

Dr. Ayan Panja 25:13 Yeah

Dr. Rangan Chatterjee 25:13 ... an acute problem with some really-

Dr. Ayan Panja 25:15 Mm

Dr. Rangan Chatterjee 25:15 ... potentially dire circumstances. And you can't just fit that narrowly into, "Oh, I've been allocated five minutes-

Dr. Ayan Panja 25:20 Mm

Dr. Rangan Chatterjee 25:20 ... for this call," or-

Dr. Ayan Panja 25:22 Exactly

Dr. Rangan Chatterjee 25:22 ... you know, it's suddenly you could still be there 45 minutes later, 50 minutes trying to talk to people, trying to find out what's the right thing, and then, of course, your existing work is still there.

Dr. Ayan Panja 25:32 Yeah.

Dr. Rangan Chatterjee 25:33 Um, I, I, I don't want this conversation to be, um, you know, a negative thing about general practice or the state of-

Dr. Ayan Panja 25:41 Mm

Dr. Rangan Chatterjee 25:43 ... um, the state of things at the moment.

Dr. Ayan Panja 25:44 Mm.

Dr. Rangan Chatterjee 25:44 There is a problem. There's not enough doctors.

Dr. Ayan Panja 25:47 Yeah.

Dr. Rangan Chatterjee 25:47 We also recognize that patients are very frustrated. They can't get the help-

Dr. Ayan Panja 25:50 Mm

Dr. Rangan Chatterjee 25:50 ... that they want.

Dr. Ayan Panja 25:51 Mm.

Dr. Rangan Chatterjee 25:52 One of the things I think is fantastic about your new book, The Health Fix, is that it's very empowering for people.

Dr. Ayan Panja 25:58 Mm.

Dr. Rangan Chatterjee 25:59 And I think it's really, really needed, Ayan, at the moment because, as you say, a lot of people can't get help. But I think what they'll find when they read your book is that there is a lot that they can do to help themselves. Do you know what I mean?

Dr. Ayan Panja 26:14 Yeah, I hope so. Yeah. That's w- one of the reasons for me writing it. If you can't sort of find tools to maximize your wellbeing in an easy way, you know, then y- you're, you're not in trouble, but you're gonna struggle to sort of-

Dr. Rangan Chatterjee 26:31 Yeah

Dr. Ayan Panja 26:31 ... find help easily, I think. That's the thing, you know, for lots of reasons as we've just discussed.

Dr. Rangan Chatterjee 26:36 Now, one of the core concepts you talk about in the book at the start is this difference between systems and symptoms. What do you mean by that?

Dr. Ayan Panja 26:49 What, what I, I mean in the book is that symptoms, which can be anything from, you know, just anything that you feel is wrong as a human being, you know, pain in your hands or bloating after meals or headaches, you know, those are symptoms, aren't they? Symptoms often, but not always, but often come from the fact that one of your biological systems in your, you know, biology has effectively started to malfunction or gone wrong, one or more systems. And those systems are your gut, your immune system. There's a big overlap between the two because a lot of the immune system's in the gut. Your musculoskeletal system, your nervous system, your endocrine system, which is your network of hormones, and your cardiovascular system. And if you think about those systems, they're all sort of working at the same time, but they're all communicating with each other. So a really simple example of this is, you know, I've done this countless times, you know, when I was a student. If you stay up really late, um, revising for an exam, have 10 cups of coffee 'cause you've not quite done enough, and then you have no sleep all night, and you go into the exam at 9:00 in the morning. If you think about what's happening to your gut, your heart rate, your brain, you know, your stomach will be churning, your heart will be going at 100 at least, and, you know, you, you'll have a banging headache. Those... What I've just described there are three systems, you know, which are intercommunicating with each, with each other, but also slightly malfunctioning because you've done the wrong thing for, for the last 12 hours or so. And in many ways, that process of your systems malfunctioning, that was an example of, um, you know, a, a one-off because you stayed up all night and had too much caffeine and, you know, you're stressed. But that happens in slow motion to us as time goes on. Your systems can begin to malfunction. And in the book, I describe it and, and use an analogy of the water leak. So, you know, imagine your shower leaks, you know, and so there's lots of options for this. You can either sort of see the brown patch on your ceiling and paint over it. Not a good idea, um, 'cause if you do that, what's gonna happen is that the water keeps leaking, and then eventually... You know, think of the systems in your house, exactly the same as in the body. You know, you've got your Wi-Fi, your electrical system, your plumbing. You know, you've got, um, carpentry, all sorts of things. You know, that, that leak will start to sort of leak down into the wall, then mold will set in, then it might leak into the light switch on the ground floor and affect your electrics. You know, so one system going wrong can then start to affect other systems, just like that example I gave you about staying up all night and what you'd feel in, you know, your heart and your head-

Dr. Rangan Chatterjee 29:37 Yeah

Dr. Ayan Panja 29:37 ... and your, you know. So, so it's a bit simplistic, but it, it's a, it's a key concept because... And, and what I don't want is people rushing off to their doctors going, "Oh, I've got a bit of a pain in my finger. I've heard it can be a problem with my systems." No. That-

Dr. Rangan Chatterjee 29:50 [laughs]

Dr. Ayan Panja 29:50 ... that's not it, you know, because, you know, there's a difference between things that happen overnight and things that happen in slow motion. But if you generally sort of got a persistent symptom, um, you know, like for example migraine headaches is a classic one, that, you know, we know that migraines have an inflammatory component, you know. And, and it- that is an example where sometimes there is some systemic inflammation and actually if you make adjustments to your lifestyle, essentially your behaviors and your environment, which is how I define it in the book- You know, then your symptom can get better because your systems are working better.

Dr. Rangan Chatterjee 30:28 Yeah.

Dr. Ayan Panja 30:29 Mm.

Dr. Rangan Chatterjee 30:29 I, I think it's a really good analogy because we often, and I think we're taught to do this as doctors as well, we overly focus on that symptom, don't we? You know, we, we see the brown patch on the ceiling, which is what the patient has come in with-

Dr. Ayan Panja 30:47 Mm

Dr. Rangan Chatterjee 30:47 ... you know, the headache.

Dr. Ayan Panja 30:48 Yeah.

Dr. Rangan Chatterjee 30:48 Right? So in the house, as you say, we could just paint over the brown patch.

Dr. Ayan Panja 30:54 Mm.

Dr. Rangan Chatterjee 30:55 And yeah, temporarily, it appears that there's no problem, especially if water's not leaking, right? That's a little bit like-

Dr. Ayan Panja 31:01 Mm

Dr. Rangan Chatterjee 31:01 ... giving a pharmaceutical medication to take away the pain of that headache, right? Same kind of concept.

Dr. Ayan Panja 31:08 Mm. Mm.

Dr. Rangan Chatterjee 31:10 But if we don't do a bit of investigating and, and figure out, well, where's that brown patch in the ceiling coming from?

Dr. Ayan Panja 31:16 Yeah.

Dr. Rangan Chatterjee 31:17 There's kind of two things the way I see it. Number one, we're not getting to the root cause of the problem.

Dr. Ayan Panja 31:22 Yeah.

Dr. Rangan Chatterjee 31:22 But number two, as you pointed out, not only are we not getting to the root cause, we're allowing that issue to keep going, which in turn, as you say, can start to affect other things in the house. So, you know, using the house analogy, your Wi-Fi's not working, you think, "What's going on?" Right? You, you look at the Wi-Fi box, you phone up the Wi-Fi operator, but actually that's a downstream consequence of the fact that you didn't fix the leak. And-

Dr. Ayan Panja 31:50 Yeah

Dr. Rangan Chatterjee 31:51 ... it's not overly simplistic at all. I think that's a very, very good analogy for a lot of the common problems that people struggle with, and how in medicine we're often overly focused on the symptom. Of course, it's important what that symptom is, but what's driving it-

Dr. Ayan Panja 32:07 Mm

Dr. Rangan Chatterjee 32:07 ... is just as important, isn't it?

Dr. Ayan Panja 32:08 Yeah.

Dr. Rangan Chatterjee 32:09 Sorry to interrupt the conversation. We'll be back in just a moment. Now, to live a long and healthy life, it can be really helpful to understand what's going on inside your body. People age at different speeds, and the typical annual blood work doesn't properly evaluate your biological age, but InsideTracker does. InsideTracker is a truly personalized nutrition and performance system that's designed to extend your health span and slow down the aging process. InsideTracker uses your test results to give you personalized recommendations on things that you can actually control, like food, supplements, workouts, and other lifestyle choices. For a limited time, you can get 20% off the entire InsideTracker store. All you have to do is click on the link in the description box below and use the discount codes LIVEMORE.

Dr. Ayan Panja 33:00 Absolutely right, and, and I think that's the thing. It, you know, it- you've nailed it really. I mean, that's, that's what this is all about. It's about looking upstream, you know? And, and, and actually, you know, the, what the book is sort of about is it's a toolkit that allows you to improve your health in simple ways by understanding the story of yourself. You know? It's totally tailored to the individual, you know? And that allows you to get to the root cause 'cause w- we'll come onto the book maybe in a bit in terms of the structure, but at the end, there's this whole section on the fixes, you know, which are-

Dr. Rangan Chatterjee 33:38 Mm

Dr. Ayan Panja 33:38 ... effectively hacks. And I know a lot of people will want to jump straight to that bit thinking, "Oh, hang on. There's no point in reading the whole th- It won't work. There's no point," A, because most people don't need all of them, and B, it won't be tailored to you. You've got to lay out your story, you know?

Dr. Rangan Chatterjee 33:52 Yeah.

Dr. Ayan Panja 33:52 Um, and that, that helps you get to the root cause much more quickly.

Dr. Rangan Chatterjee 33:57 One of the ways you help people and readers understand what they need to do, not what their brother needs to do, or their sister, or their partner, or their mate, right?

Dr. Ayan Panja 34:11 Mm.

Dr. Rangan Chatterjee 34:11 What they need to do is with something you call the health loop.

Dr. Ayan Panja 34:14 Mm.

Dr. Rangan Chatterjee 34:15 Right? So explain to us what's the health loop and, and why is it so effective?

Dr. Ayan Panja 34:19 Y- yeah. The health loop is really a, a, a collection of eight factors that give rise to your health right now. So you and I right now, our state of health is based on these eight factors, and they are, not in any particular order, sleep, stress, diet, exercise, your genetics, your environment, historic infections, and your exposure to sunlight. That last one is also a euphemism for vitamin D levels, but... And if you think about those things, you know, when, when, when a patient is sort of telling me a story and it's all a bit nebulous, so it's not the story of, "Yeah, I had a fall and I've broken my elbow. I need a sick note." That's quite defined. No need for the health loop. But if it's kind of like, "You know, I'm just not feeling right. I've got all sorts of things going on. Um, you know, I'm t- tired all the time. I've got pains in my joints. I've got headaches," you know, how I felt basically when I was, when I was about 40. But, but the point is that, you know, th- that needs slightly different antennae because if you're using the kind of conventional medical model, you know, and I'm not saying this is alternative in any way, but if you're using, you know, the training that I, I had and you had, and how I would've approached that 20 years ago, I would've listened very attentively and been very compassionate, but I would've dealt with all of those things individually going, "Well, why don't you try an anti-inflammatory for your joint pains, and then I'll give you some, you know, proton pump inhibitor for your gut, and you know?" But actually, all of those things might be connected if, if your systems are kind of not functioning well. And if you, if you look at those factors, everything that I've just laid out, stress, sleep, diet, movement, the easiest way to get that out of someone is by asking them, "Tell me about your typical day." You know, that's the thing I sort of... And in the book, I, I get someone to think about their typical day because most of those things will drop out of them. Some of them won't. Genetics won't because you need to know what your family history of illnesses are. Um, and- Other, other things are kind of n-not always that, that obvious, but, you know, again, when you tell your own story, you kind of think, "Wait a minute. Actually, I am working like 14 hours a day. Maybe, maybe that's why I'm tired." [laughs] You know, you just don't see it, do you?

Dr. Rangan Chatterjee 36:41 Yeah.

Dr. Ayan Panja 36:41 Unless you, you, you think about it.

Dr. Rangan Chatterjee 36:44 Yeah. I, I think the Health Loop's brilliant, actually. It's these eight key factors that pretty much are the contributory factors to all chronic illness.

Dr. Ayan Panja 36:54 Mm. Yeah.

Dr. Rangan Chatterjee 36:54 You know? It's that simple, right? And I think the way you've done it is, is really, really helpful, especially, as you say, for people who've got, you know, a variety of different things. You know, it doesn't neatly fit into-

Dr. Ayan Panja 37:07 Mm

Dr. Rangan Chatterjee 37:07 ... a particular box, that you've got this problem or that problem. It's just generalized symptoms that are meaning they're not thriving in life.

Dr. Ayan Panja 37:15 Mm.

Dr. Rangan Chatterjee 37:15 Everyone wants to thrive, don't they?

Dr. Ayan Panja 37:17 Mm.

Dr. Rangan Chatterjee 37:18 Um, you've got some brilliant cases. I wonder if we can talk about Amelia.

Dr. Ayan Panja 37:21 Mm.

Dr. Rangan Chatterjee 37:21 Uh, because Amelia in the book, I think, beautifully illustrates-

Dr. Ayan Panja 37:25 Mm

Dr. Rangan Chatterjee 37:25 ... just how powerful the Health Loop can be and how quickly it can work.

Dr. Ayan Panja 37:30 Yeah. Yeah. I, I, I'd agree. Yeah. So she'd gone from being this really healthy university student who was like a sports champion at hockey, tennis, and various other sports, and, um, had gone from being, from thriving, I guess, to being near bedbound, you know, to the point where she just could not function. So she'd get up and then go back to bed, wasn't able to train, wasn't able to continue with her studies for a while. And, um, and the ... It was, it was a bit of a mystery. She'd already seen doctors who'd sort of said, "Look, don't know what it is. It must be viral, you know. Just keep on kind of, you know, doing what you're doing," type thing. But... And, and what, what the Health Loop laid out in her case was that... In fact, she, she, you know, her dad, um, um, accompanied her to the appointment and basically said, "Look, you know, she's, um, never really been ill. She's a very, very healthy person. This is just totally not, not like her." And actually, to start with, nothing was coming out. You know, her typical day, she goes... Her typical day then was, "Look, I just... I get up and have breakfast, you know, cereal or toast, and I just sort of, I feel really tired, and then I can ... You know, I, I kind of go to lectures, but I can't really... I'm falling asleep by the middle of the afternoon, and I can't do any netball training," and, and all that, all that sort of stuff, which she used to do in the evenings. So, so when I met her, her, her typical day was terrible, but her... what we'd call in medicine her premorbid, you know, typical day, which means before she got ill, she was super active. She was just full of energy. And then I go, okay, well, tell... Let's... And, and one of the things that you, we do in the book, um, is also something called a timeline. So it's really important to look at someone's early life, and there's, there's a whole, a whole section in the book about how our early life affects us as adults, you know, both mentally and physically in terms of health. And the example I would give is if you've got someone who is perhaps, you know, born premature, not breastfed, um, has lots of infections when they're young. Just those three factors will affect this person's health later. They're more likely to get gut symptoms or fatigue-

Dr. Rangan Chatterjee 39:48 Mm

Dr. Ayan Panja 39:48 ... for in... because of insults to their gut flora. But we can come back to that later. But the point was Amelia had none of these. Nothing. And so I remember going through the years going,, "Okay, that's weird." I go, "What about when you were 10 or 11? Anything then?" And, you know, her and dad are going, "Nope." "Right. Okay. 12, 13, 14? Don't remember anything from your teenage years?" Like, "Nope." It's like never been in hospital. So I wasn't really getting very much. And, um, and then suddenly came this revelation that she'd, um, split up with her boyfriend, fallen out with a friend, and had two urine infections all in the space of a few months. They sound quite innocuous, don't they?

Dr. Rangan Chatterjee 40:30 Mm.

Dr. Ayan Panja 40:30 But, so a spike of... thinking of the Health Loop, a spike of stress. Infections is one of the spokes in that, you know, loop as well. Um, and two lots of antibiotics. And I suddenly thought, do you know what? That could be enough just to tip... You know that thing that you always talk about, about tipping points and how everything's at a threshold, and she just reached her threshold. She'd been sort of managing quite well for 18 and a half years, you know, with what I'd call a beige diet. You know, she wasn't particularly... You know, she got away with just sort of living on non-nutritious food. I'm not judging at all but, you know, a lot of teenagers do that, and that's fine. But, but, uh, suddenly the stress and the insult to her gut flora tipped the balance. The only other thing was her brother has celiac disease, which was at the back of my mind. And often, you know, everyone with celiac disease, pretty much 99% of people, have these two gene haplotypes, a particular genetic marker. But she'd been tested for celiac disease, and it was negative. She didn't have antibodies to it. So anyway, she had sort of big end of year exams coming up, and that's why the pressure was so high. And I, I remember saying to her, "Look, you know, I, I think I know what's going on here." And there was, there were a number of interventions that we had to make. The first one was changing, um, what she ate. She just loved beige food, you know, um, like most teenagers. Nothing wrong with that, but, you know, it's not particularly nutritious. She sort of lived on cereal, toast, pasta, you know, that sort of student diet. So I wanted her to improve her diet a little bit by introducing more nutrients, really, vegetables and fruit and... You know, she used to eat a bit of fruit, but not very much. Then I noticed that she, she's a very quick eater, and one of the concepts in the book is how, what, and when. It's not just eat more healthily, you know. It's how you eat, what you eat, when you eat. And there were two things that stood out. One was that she liked snacking before bedtime. Which is a bit of a disaster 'cause it disrupts sleep and, you know, it's just not, not good for you for lots of reasons 'cause you end up with a high spike in blood glucose and then a high insulin level when, while you're asleep. Um, but that wasn't the reason for this. It was more to try and help her sleep. So I, I stopped her snacking at bedtime, and I wanted her to eat more slowly. So that was the sort of eating bit. Um, I also detected that she was quite stressed. There was a lot of pressure on her in terms of exams, and she's obviously a top-level sports person. So I asked her to do nothing for five minutes a day. When I say nothing, it's a bit like my one-minute recharge, where you just zone out and kind of do something to kind of make yourself feel relaxed. So she was quite up for this, but hadn't really realized that she doesn't get any downtime.

Dr. Rangan Chatterjee 43:24 Mm.

Dr. Ayan Panja 43:25 She, you know, she's always on the go. She's quite competitive. And the last thing, because of the story of the antibiotics, I figured her gut flora were shot, you know? And so I put her on a probiotic, something called Lactobacillus GG. It's the one that most of the studies are done on if people, you know, look it up online. And, um, and really, that, that, that was it. And what was remarkable that, was that very quickly, within a matter of weeks, she was almost back to normal, having been in this state of feeling unwell for six months. And I, I remember thinking about this at the time, and she's really a case of evolving autoimmunity. You know, she was on this march towards autoimmunity, and people will sort of say, "Well, you can't prove that," you know? Um, and, uh, but, but the, the alternative was that she was being labeled as someone that might have chronic fatigue, you know? That was what was going on with the doctors she'd seen already. They were going, "Well, maybe it's just ... Maybe you got chronic fatigue. I don't know, you know? Maybe it's post-viral." You know, all this kind of conjecture. And, and just thinking about what she did there to help herself, you know, we, we ... It's all in the story, you know? So you've got this very well person who suddenly has a couple of, you know, blips in terms of stress, um, relationship breakups, and then has two urine infections, which people get all the time, two courses of antibiotics. Bear in mind that one course of antibiotics can sometimes wipe out ... They can't tell the difference between good and bad bacteria, so they wipe out all the good stuff, all the good bacteria in the gut, which is effectively the food for our immune system. So y- y- ... In, in a lot of people, it doesn't affect them. But, but for her, it obviously did, and it, and that triggered a number of things. Her symptoms were fatigue, bloating, um, lack of energy, and also some sleep disruption. You know, everything, a, a little bit like people who get COVID and then end up with long COVID. They get ... All of their body systems just seem to be affected. They get this dysautonomia, and actually, Amelia had that. She, she kept sort of ... You know, I don't think I, I talk about it much in the book, but she was feeling faint and kind of dizzy and all, all of that sort of stuff as well. And w- what was going on there? Well, there's two things. Well, three things, really. One is we haven't come to the bit about her brother having celiac disease, which we can come back to, 'cause that may be relevant. So one of the things that her new diet did, it sort of removed pr- ... She, she went ... She's a real all or nothing sort of person, so she went all in and kind of removed all the beige stuff. So she was r- ... You know? But that also meant she wasn't really eating any gluten. [lip smacks] And I do wonder, wonder whether she has the gene for celiac disease because, you know, there is a group of patients that I see at work who react to gluten, but they come up negative when you do a blood test for antibodies to gluten. And those antibodies, the ones in the gut, you know, or, you know, TT, anti-TTG antibodies they're called, they only really measure whether you're making antibodies at that moment in time. But they don't tell you whether you've got the gene that everyone ... I say everyone, but 99% of people who have celiac disease have a particular gene variation. You know, the, these, um, called HLA-DQ2 or HLA-DQ8. And sometimes what I'll say is I'll go, "Look, you know ..." Often it's children, and, and the parents are going, "Look, why, why does she get a bad tummy, and why is she sort of so grizzly every time she has gluten even though she's negative for celiac disease?" And I go, "Well, she might have the gene. If you've got the means, get a, get a DNA test done." I don't know with Amelia whether she ever did that, and I don't know whether she's got that gene, but it's definitely something in the background.

Dr. Rangan Chatterjee 47:31 Yeah.

Dr. Ayan Panja 47:31 Um, but so often, if, if you do have that gene, then you've got a choice because you can either think, "Right. Well, we, we're just gonna avoid gluten altogether because that way we guarantee you don't end up with celiac disease." But if you don't, then there's a 10 to 20% risk that you will develop it-

Dr. Rangan Chatterjee 47:50 Yeah

Dr. Ayan Panja 47:50 ... at some point in your life. But a bit of aside sort of-

Dr. Rangan Chatterjee 47:52 Well, th- this is super interesting, and I just wanna back up a minute-

Dr. Ayan Panja 47:56 Mm

Dr. Rangan Chatterjee 47:56 ... Ayan, because, uh, this is a very powerful case, right?

Dr. Ayan Panja 47:58 Mm.

Dr. Rangan Chatterjee 47:58 So young lady, 19 years old-

Dr. Ayan Panja 48:03 Mm

Dr. Rangan Chatterjee 48:03 ... comes in to see you with a variety of different symptoms. You know, her life is literally falling apart.

Dr. Ayan Panja 48:10 Mm-hmm.

Dr. Rangan Chatterjee 48:10 Her concerned dad brings her in and says, you know, "What's going on here?" Right? She's knackered, struggling with motivation. She's got brain fog. She's fainting.

Dr. Ayan Panja 48:20 Mm-hmm.

Dr. Rangan Chatterjee 48:21 She can't concentrate. She has some sleep disturbance. But modern medicine can't put her in a neat little box, right? We can't say, "Oh, you have this condition." Now, I know from reading it in your book, I think, that you ran some blood tests.

Dr. Ayan Panja 48:40 Mm.

Dr. Rangan Chatterjee 48:40 Because of course, fatigue ... can be many different things

Dr. Ayan Panja 48:43 Mm-hmm

Dr. Rangan Chatterjee 48:43 So the first thing you did was just double-check all those medical things first-

Dr. Ayan Panja 48:47 Mm

Dr. Rangan Chatterjee 48:47 ... right?

Dr. Ayan Panja 48:47 Yeah.

Dr. Rangan Chatterjee 48:48 Um-

Dr. Ayan Panja 48:48 Which she aced. They were totally normal.

Dr. Rangan Chatterjee 48:50 Yeah.

Dr. Ayan Panja 48:50 She had several sets of bloods. It's important, this, actually, 'cause there are some medical reasons for fatigue, and in fact, doctors, we call it tired all the time, TAT. You know, w- when we write a blood format, often we'll, we'll put that as a, a shortcut. Um, things like anemia or an underactive thyroid or type 2 diabetes, or sometimes something a bit more mysterious like Lyme disease might be the cause, or glandular fever, another very common one. I mean, these are the, the... They're not exhausted by any means, or, or vitamin D or vitamin B12 deficiency, and again, relatively, I say common, but, you know, often that will come up, but they, they didn't in, in-

Dr. Rangan Chatterjee 49:29 So, so they're, they're all ruled out.

Dr. Ayan Panja 49:31 They're all ruled out, yeah.

Dr. Rangan Chatterjee 49:31 So at that point, you know, okay, there's no obvious medical, in inverted commas, cause for this.

Dr. Ayan Panja 49:36 Yeah.

Dr. Rangan Chatterjee 49:37 And I think this is where there's a real knowledge gap in medicine. For all the brilliance of our training, it's clear to both [laughs] of us that it's good for some things and not so good for others. And I think Amelia's case is one of those classic cases that many people around the country, around the world, you know, these are symptoms they feel, yet often they draw a blank when they come and see their medical doctor. And it's not because the medical doctor doesn't wanna help them either, it's because, you know, the systems v. symptoms, uh, framework that you've already outlined, it's because we often... Well, it's because we're trained to look at those symptoms. But those symptoms, although seemingly unrelated, you know, fainting, tiredness, sleep disturbance, brain fog, actually, maybe they're just downstream symptoms of an underlying root cause like we've already mentioned with the water leak, right? It's the, the shower that's leaking upstairs that's the problem. That's why you've got a brown mark on your ceiling. That's why the Wi-Fi's not working. That's why the light isn't working in that room, that kind of pattern. So you've ruled out medically. That's when you brought in the health loop.

Dr. Ayan Panja 50:53 That's right, yeah.

Dr. Rangan Chatterjee 50:54 And, and what I find really interesting about that, because I actually think everyone listening to this, Ayan, could do their own health loop.

Dr. Ayan Panja 50:59 Yeah.

Dr. Rangan Chatterjee 50:59 You know, your books can absolutely guide them on how to do that in detail, but very broadly, you identified, I think, three or four areas, right?

Dr. Ayan Panja 51:09 Mm.

Dr. Rangan Chatterjee 51:09 Huge amounts of stress.

Dr. Ayan Panja 51:10 Mm. Mm.

Dr. Rangan Chatterjee 51:10 That's one of the eight factors.

Dr. Ayan Panja 51:12 Mm.

Dr. Rangan Chatterjee 51:12 Um, you identified, you know, recent infections.

Dr. Ayan Panja 51:17 Mm.

Dr. Rangan Chatterjee 51:17 Se- a second one of those eight factors.

Dr. Ayan Panja 51:19 Yeah. Yeah.

Dr. Rangan Chatterjee 51:20 You identified a pretty, you know, an average sort of beige diet.

Dr. Ayan Panja 51:24 Mm. Mm.

Dr. Rangan Chatterjee 51:24 Third one.

Dr. Ayan Panja 51:25 Mm.

Dr. Rangan Chatterjee 51:25 Um, and then you also identified, or you were suspicious of genes because of-

Dr. Ayan Panja 51:29 Yeah

Dr. Rangan Chatterjee 51:29 ... her brother's celiac disease.

Dr. Ayan Panja 51:30 Yeah.

Dr. Rangan Chatterjee 51:30 But what it does, it, it gives you as a doctor, and it gives people who are doing it on themselves, it gives them somewhere to go.

Dr. Ayan Panja 51:37 Mm.

Dr. Rangan Chatterjee 51:38 Right? Instead of being lost, what, what does all this mean? You go, "Okay, let's just look at the... These are the eight factors. Oh, there's four that are lighting up here. I can start addressing them, or I can start addressing one of them." At its core, mate, it's that simple, right? So let's go back to Amelia, because you brought up some really interesting things there, right? You changed her diet.

Dr. Ayan Panja 51:59 Mm.

Dr. Rangan Chatterjee 51:59 You gave her a probiotic to sort out her guts.

Dr. Ayan Panja 52:01 Mm-hmm.

Dr. Rangan Chatterjee 52:01 You helped her manage her stress.

Dr. Ayan Panja 52:03 Mm.

Dr. Rangan Chatterjee 52:03 Obviously, you didn't do anything for her genes.

Dr. Ayan Panja 52:05 No.

Dr. Rangan Chatterjee 52:06 But you mentioned in the book that she gave up gluten by accident-

Dr. Ayan Panja 52:11 Mm. Mm

Dr. Rangan Chatterjee 52:12 ... which I found, which I found really interesting, this concept that she gave it up by accident.

Dr. Ayan Panja 52:17 Mm.

Dr. Rangan Chatterjee 52:18 So let's just hone in there for a second, because this concept of evolving autoimmunity, I think-

Dr. Ayan Panja 52:23 Mm

Dr. Rangan Chatterjee 52:23 ... is really interesting.

Dr. Ayan Panja 52:25 Mm.

Dr. Rangan Chatterjee 52:25 I don't think it's something I've spoken about much on the show before.

Dr. Ayan Panja 52:28 Mm. Mm.

Dr. Rangan Chatterjee 52:29 Right? I think listeners to this show are aware now-

Dr. Ayan Panja 52:32 Mm

Dr. Rangan Chatterjee 52:32 ... that, you know, by the time they get a diagnosis of type 2 diabetes-

Dr. Ayan Panja 52:37 Mm

Dr. Rangan Chatterjee 52:37 ... that process has been going on in the body for at least 10 years.

Dr. Ayan Panja 52:42 Yeah.

Dr. Rangan Chatterjee 52:42 Right? By the time they get a diagnosis of Alzheimer's dementia-

Dr. Ayan Panja 52:45 Mm

Dr. Rangan Chatterjee 52:45 ... that process has been going on for maybe 30 years, right? So these things don't just happen overnight.

Dr. Ayan Panja 52:51 Mm.

Dr. Rangan Chatterjee 52:51 But what you're saying with evolving autoimmunity is that autoimmune disease also does not happen overnight. It is a process. It's the end stage on a continuum, and what you're saying is that for some people, these vague symptoms, if we don't get on top of-

Dr. Ayan Panja 53:09 Mm

Dr. Rangan Chatterjee 53:09 ... and start to help people with, they are going to keep evolving, this evolving autoimmunity.

Dr. Ayan Panja 53:16 Mm.

Dr. Rangan Chatterjee 53:16 And as you say, with Amelia, with, with-

Dr. Ayan Panja 53:18 Yeah

Dr. Rangan Chatterjee 53:19 ... with that genetic history in her family as well, it may well have ended up with a diagnosis of autoimmune disease five, 10 years down the line, right?

Dr. Ayan Panja 53:26 Yeah, yeah, yeah. Absolutely, and it... You, you're right, and I, I think going, you know, one step back from that, if you, if you're lucky, you know, and, and, and actually, if you look at the factors in the health loop, you know, i- if you don't have any genetic predisposition to autoimmunity, and you don't have... You've never had very bad glandular fever as a, an infection, 'cause viruses can prime you for autoimmunity, and if you haven't got any of those risk factors, and you're relatively lucky, and you do all the basics right in terms of sleeping, eating, and exercise, and all of those things, you'll probably be okay. But that's not real life, you know, and most of us are primed. You know, I am, definitely, 'cause I had something called dengue fever years ago, and, you know, I don't wanna go into my own story at this point, but, you know, you, you know, I, I talk about it briefly in the book at the beginning. But, but, um, so, so, so you, you're quite right. You can lay out the, the story for yourself so that it, it tells you exactly where to focus, and that... I think that's the point, you know.

Dr. Rangan Chatterjee 54:31 Mm.

Dr. Ayan Panja 54:31 Rather than this scattergun approach of, uh... 'Cause there's inf- there's so much info out there these days, isn't there, in terms of public health messaging? But when it's you yourself with problems that are not being resolved, or you're slightly stuck, then you need a different lens and a different approach, and this is just a very logical, very sort of s- you know, easy way to lay it all out for yourself.

Dr. Rangan Chatterjee 54:53 Yeah. Let's just complete the loop on the triad, the three things-

Dr. Ayan Panja 54:58 Mm

Dr. Rangan Chatterjee 54:58 ... that are needed ... for autoimmune disease, because I think that's gonna help make this really, really clear

Dr. Ayan Panja 55:04 Yeah. Yeah, absolutely. So my understanding of autoimmunity and why people get it, how it starts, and how it evolves, is that you need three things. So one is a genetic predisposition. So if you've got a family history of an autoimmune disease, you're more likely to develop an autoimmune disease. The second one is an environmental trigger, and that can be... And this is real-world stuff and also written in the scientific papers. This isn't woo woo. The environmental trigger can be anything from very high stress levels, to a viral infection, to, you know, some other form of inflammatory process. It can be, it can be lots of things, but very commonly, viruses and life events, very high levels of stress. You know, we see this time and time again in, in general practice. And the last one is something called increased intestinal permeability. This is one that's quite contentious and theorized. There's lots of papers on this, and it-- the theory for that one, th- well, there's two things. Firstly, that's the only one you can really do anything about, 'cause you can't really change-- well, you can't change your genes. Well, apart from gene editing, but you can't change what's happened, you know, in previous gener- generations in terms of family history. If you've had the environmental trigger, that's in your past, that's in your timeline. But intestinal permeability, um, and the... And, and just to talk a bit about that, what that means is that in the small intestine, there are these things called tight junctions, a little bit like those sort of gaps on the side of the, the motorway that sort of, you know... There, there's a gap, but they're kind of sealed off so that cars can't get through. Um, and when you have increased intestinal permeability, molecules that are meant to be within the gut lumen effectively leak through these tight junctions into the bloodstream and cause inflammatory effects. And so, you know, particularly for medics who are interested in this, but I'm, I'm sure other people will be, there's something in medical textm- textbooks called blind loop syndrome. Do you remember this?

Dr. Rangan Chatterjee 57:12 Yeah.

Dr. Ayan Panja 57:13 So blind loop syndrome is, is... It's in surgical textbooks, and I remember years ago reading about it, thinking... And it said, oh, blind loop syndrome can also be associated with rashes, and joint pains, and other systemic symptoms. And I, I do remember, you know, 30 years ago, whenever it was, thinking, "That's a bit weird. Why would something in the gut give you rashes?" And actually, if you think about this theory of intestinal permeability, it makes total sense. 'Cause those kind of molecules that then leak into your bloodstream and activate inflammatory mediators give you systemic effects, meaning that they affect all your systems. You suddenly start to get headaches, joint pains, you know-

Dr. Rangan Chatterjee 57:53 Mm

Dr. Ayan Panja 57:54 ... rashes. Um, and there's a, there's a very specific type of condition called SIBO, or small intestinal bacterial overgrowth, that, where that, that process of increased intestinal permeability is at play.

Dr. Rangan Chatterjee 58:10 Yeah.

Dr. Ayan Panja 58:10 Um, and that, uh, to, to cut a long story short, it's when you basically have more bad bacteria in your gut than good bacteria. The balance is tipped, and that is sometimes one of, one of the triggers for autoimmunity in the gut. You know, beyond your environmental trigger and beyond the fact that you've got a genetic predisposition. So it's... It-- You know, but the point is that you, if you catch it sort of early enough and you spot the signs, which is difficult, I have to say. I mean, this-- The, the thing with Amelia was she was pretty desperate. You know, she was really quite, you know, really not well. You know, she wasn't functioning, and that's why, um, it was so obvious when she got better that she was better. Um, but, but I don't think, you know, in, in, in defense of her and p- people who'd seen her before, it w- probably wasn't that bad four months before. She was just a-

Dr. Rangan Chatterjee 59:00 Mm

Dr. Ayan Panja 59:00 ... bit under the weather. It had just got worse, and worse, and worse. But, but, you know, if I had to... If I was a betting man, I would say she was definitely on that march towards autoimmunity.

Dr. Rangan Chatterjee 59:10 Yeah, I found the triad.

Dr. Ayan Panja 59:13 Mm.

Dr. Rangan Chatterjee 59:13 I think it was the immunologist, Aristo Vojdani, who-

Dr. Ayan Panja 59:16 Mm

Dr. Rangan Chatterjee 59:16 ... initially came up with that triad-

Dr. Ayan Panja 59:17 Mm

Dr. Rangan Chatterjee 59:17 ... from recollection, that you need these three things to get autoimmune disease. You know, the genetic predisposition-

Dr. Ayan Panja 59:25 Mm

Dr. Rangan Chatterjee 59:25 ... environmental trigger-

Dr. Ayan Panja 59:27 Mm

Dr. Rangan Chatterjee 59:27 ... and increased intestinal permeability, also known as leaky gut.

Dr. Ayan Panja 59:32 Mm.

Dr. Rangan Chatterjee 59:33 Um, I've always found it really helpful, you know, when assessing patients. It, it's a great lens through which to look at it, you know? A- and then if we look at Amelia for a minute, she absolutely fits, doesn't she? You know.

Dr. Ayan Panja 59:47 Mm.

Dr. Rangan Chatterjee 59:47 That, that we don't know her genes.

Dr. Ayan Panja 59:49 No.

Dr. Rangan Chatterjee 59:49 But given that her brother is celiac, you know-

Dr. Ayan Panja 59:53 Yeah

Dr. Rangan Chatterjee 59:53 ... i- it's not unreasonable to assume that there may be-

Dr. Ayan Panja 59:56 Mm

Dr. Rangan Chatterjee 59:56 ... some genetic predisposition there.

Dr. Ayan Panja 59:58 Yeah.

Dr. Rangan Chatterjee 59:58 But I think that's that key point, that the genes you're born with, it's just a predisposition. If you don't have the other two things, the environmental trigger and the, the leaky gut-

Dr. Ayan Panja 1:00:09 Yeah

Dr. Rangan Chatterjee 1:00:10 ... it's not gonna happen.

Dr. Ayan Panja 1:00:11 Mm.

Dr. Rangan Chatterjee 1:00:11 You're very unlikely to get that autoimmune disease.

Dr. Ayan Panja 1:00:14 Mm. Mm.

Dr. Rangan Chatterjee 1:00:17 Um, I wanna just pause on these genes-

Dr. Ayan Panja 1:00:19 Mm

Dr. Rangan Chatterjee 1:00:19 ... a minute, because gluten is something that a lot of people talk about.

Dr. Ayan Panja 1:00:22 Mm-hmm.

Dr. Rangan Chatterjee 1:00:23 And again, like many things online these days, things become quite black or white.

Dr. Ayan Panja 1:00:31 Mm-hmm.

Dr. Rangan Chatterjee 1:00:31 Like, the extreme... The, I would say the current-

Dr. Ayan Panja 1:00:34 Mm

Dr. Rangan Chatterjee 1:00:34 ... view by most of society, and many healthcare professionals, is the only reason to exclude gluten from your diet is if you have a confirmed diagnosis of celiac disease.

Dr. Ayan Panja 1:00:46 Mm. Mm-hmm.

Dr. Rangan Chatterjee 1:00:47 Right? Now, I actually don't agree with that. Sorry to interrupt. If you are enjoying this content, there's loads more just like it on my channel, so please do take a moment to press Subscribe, hit the notification bell, and now back to the conversation. That doesn't fit with my clinical experience personally. I think there are, um, nuances here There are people-

Dr. Ayan Panja 1:01:09 Mm

Dr. Rangan Chatterjee 1:01:10 ... time and time again, who when they exclude gluten from their diets, starts to feel better.

Dr. Ayan Panja 1:01:15 Mm.

Dr. Rangan Chatterjee 1:01:16 F- and there could be many reasons for that.

Dr. Ayan Panja 1:01:18 Yeah.

Dr. Rangan Chatterjee 1:01:18 Because it, you know, is it the gluten? Is it the kind of products that gluten is in, and therefore, when you exclude that, you're no longer having those things?

Dr. Ayan Panja 1:01:25 Mm.

Dr. Rangan Chatterjee 1:01:25 You know, like FODMAPs, for example. But do you know what I mean? I m- how do you see this?

Dr. Ayan Panja 1:01:31 Yeah, no, I, I, I agree. The problem is that there's a sort of perceived wisdom in the scientific community that is quite sort of rigid and concrete. Um, I, I, I do touch on this in the book, and there's a whole bit on the importance of evidence-based medicine, but also when there's no evidence, you know, how ridiculous it can seem. And, um, but go- going back to what you said about is there a reason to exclude it, um, if you don't have celiac disease. So for example, patients, um, with Hashimoto's disease, which is a thyroid condition, it's an autoimmune thyroid condition, do very well on a gluten-free diet. Why is that? The reason is a very well-established scientific concept called molecular mimicry, and what that means is that the proteins on the thyroid gland resemble gluten in terms of their shape. Just imagine it's this shape, and that means every time... So just to clarify, Hashimoto's disease is when you make antibodies to your thyroid. So you've got antibodies attacking your thyroid tissue. But the thyroid tissue looks like gluten to the immune system. So every time you eat gluten, guess what? Those thyroid antibodies will be activated, and you'll again get this flare up of thyroid symptoms. And so, you know, i- it doesn't work for everyone, but certainly that group of patients, if they go on a gluten-free diet, feel a lot better 'cause they're not getting the antibody response as much.

Dr. Rangan Chatterjee 1:03:10 Mm.

Dr. Ayan Panja 1:03:11 Um, molecular mimicry is something that's, it's, it's very well established. A really well-known example of this is oral allergy syndrome and allergy to birch pollen. So if you're someone who eats fruits and then your lips swell up, you're probably also allergic to birch pollen because it's exactly the same thing. The actual shape of the molecules are so similar that it tricks your immune system.

Dr. Rangan Chatterjee 1:03:35 Mm.

Dr. Ayan Panja 1:03:35 It's a case of mistaken identity effectively. Um, so I don't agree with that. I think there are instances where a gluten-free diet would benefit. The o- the other group I see it in are people who, um, have... You know, I get this a little bit, so I c- I can eat certain types of gluten, but other types really just, honestly, it's, it's like I've been poisoned. I've often wondered why it is, 'cause I, I don't have celiac disease and I don't have the gene actually for celiac disease.

Dr. Rangan Chatterjee 1:04:06 Really?

Dr. Ayan Panja 1:04:06 Yeah, 'cause, um, so I, I don't have them. So why do I react to it? Who knows? But the point is I, I do and, and I think for me it's because my, um, environment, my autoimmune trigger is I had dengue fever in my 20s, which is a, quite an, quite a nasty virus. I was very, very ill with it. Um, and viruses prime your immune system. Not all viruses, but they can prime your immune system for autoimmunity. So Epstein-Barr virus, which is the one that causes-

Dr. Rangan Chatterjee 1:04:36 Mm

Dr. Ayan Panja 1:04:36 ... glandular fever or human herpes virus 6, HHV6 is another one. Very common virus, but in, in some people prime you for autoimmunity. Um, and then all you need is another trigger. So, you know, my own illness, which I describe in the book, was a mixture of that. No sleep. I say no sleep, but almost no sleep for three years, and then a huge spike in stress. And just those three things in my health loop were enough to just tip the balance for me.

Dr. Rangan Chatterjee 1:05:04 Mm.

Dr. Ayan Panja 1:05:04 So yeah, you know, it, that's the way I, I like to look at it.

Dr. Rangan Chatterjee 1:05:08 Yeah. There, there's so many interesting points there, Ayan, which I think are really worthy of discussion. You said something that I think is incredibly powerful, which is, "I don't know why I'm sensitive to certain types of gluten-" [laughs]

Dr. Ayan Panja 1:05:30 Mm

Dr. Rangan Chatterjee 1:05:31 ... "but I am."

Dr. Ayan Panja 1:05:32 Mm.

Dr. Rangan Chatterjee 1:05:34 That's good enough, right? But you know, when someone then says, "Well, you don't have a diagnosis of celiac disease, you shouldn't be excluding it. There is no reason to do it," which people say.

Dr. Ayan Panja 1:05:46 Mm.

Dr. Rangan Chatterjee 1:05:46 Like really well-respected scientists say. To me, it just shows a complete lack of real-world understanding of what actually goes on in people's lives. It's all very well to study something in the lab-

Dr. Ayan Panja 1:05:58 Mm

Dr. Rangan Chatterjee 1:05:58 ... or in the scientific journals, but why I think the approach that you've outlined in your book is gonna help so many people is because it's based on real-world clinical experience. We all know that feeling as a, as a doctor, any healthcare professional, when there's a patient sitting in front of you in pain of some sort.

Dr. Ayan Panja 1:06:20 Mm.

Dr. Rangan Chatterjee 1:06:20 They're struggling with their life, whether it's Amelia as a 19-year-old or someone older, you know, they can't think properly. They've got joint pain. They, they've got anxiety, what- whatever it might be, and often the science doesn't give you the answer of what to do.

Dr. Ayan Panja 1:06:37 No.

Dr. Rangan Chatterjee 1:06:37 Right?

Dr. Ayan Panja 1:06:38 Yeah.

Dr. Rangan Chatterjee 1:06:38 That's the truth. It's like, [laughs] you know, you use the science to help guide you.

Dr. Ayan Panja 1:06:42 Yeah.

Dr. Rangan Chatterjee 1:06:42 But ultimately you go, "Well, okay, what's relevant for this person?" And then there is also something about clinical experience and clinical expertise.

Dr. Ayan Panja 1:06:49 Mm.

Dr. Rangan Chatterjee 1:06:49 You're going, "You know what? This patient reminds me of that one I saw last month who-

Dr. Ayan Panja 1:06:54 Mm

Dr. Rangan Chatterjee 1:06:54 ... this works for."

Dr. Ayan Panja 1:06:55 Mm.

Dr. Rangan Chatterjee 1:06:56 And it's not the science that's not important. Of course, it's important. Do, do you know what I'm getting at?

Dr. Ayan Panja 1:07:01 Yeah, yeah. I, it, it is, and I think practitioners, you know, they have their own internal sort of gut feeling and evidence base, and I think the, the difficulty is, is that science You know, is, is, is advancing as we know. But with it, there, there are a lot-- You know, what, what this book isn't and, and is almost the opposite of is, is apps and aids that sort of tell us about things like heart rate variability and, you know, what, what your, what your, what, what's going on. 'Cause data is, is, is king, isn't it? I mean, data's just so amazing. But it can be quite confusing if you can't put it into context. And I think if, if nothing else, this book puts your health into the context of your life more than anything else that I think is out there.

Dr. Rangan Chatterjee 1:07:51 Yeah. We've mentioned a health loop.

Dr. Ayan Panja 1:07:54 Mm.

Dr. Rangan Chatterjee 1:07:55 You also mentioned something called a timeline, and I just wanna reiterate that doing a timeline on a patient is incredibly helpful.

Dr. Ayan Panja 1:08:04 Mm.

Dr. Rangan Chatterjee 1:08:04 But do it on yourself.

Dr. Ayan Panja 1:08:06 Yeah, it's amazing, isn't it?

Dr. Rangan Chatterjee 1:08:07 It, it's-- If someone was just to sit there for twenty minutes and do their own timeline and plot out everything, all the big moments in their life from childhoods, I think people will see patterns, and it's, it's, it's just incredible when you, you know, with a patient, sort of go through their story.

Dr. Ayan Panja 1:08:27 Mm.

Dr. Rangan Chatterjee 1:08:27 Now, you need a bit of time to do this, for sure.

Dr. Ayan Panja 1:08:30 Mm. Mm.

Dr. Rangan Chatterjee 1:08:31 And you can almost see the realization in them when they, they go, "Oh, yeah. You know what? I used to get ear infections all the time. I, I was on antibiotics every two months-

Dr. Ayan Panja 1:08:41 Mm

Dr. Rangan Chatterjee 1:08:42 ... when I was a kid for five or six years. Then this happened when I was fourteen, and then-

Dr. Ayan Panja 1:08:46 Mm

Dr. Rangan Chatterjee 1:08:46 ... my parents got divorced at this point, and then, oh, I got sick just after that."

Dr. Ayan Panja 1:08:51 Mm.

Dr. Rangan Chatterjee 1:08:52 Like, it's so-

Dr. Ayan Panja 1:08:52 Mm

Dr. Rangan Chatterjee 1:08:52 ... obvious sometimes when you see it, isn't it?

Dr. Ayan Panja 1:08:55 Yeah. Sometimes they just burst into tears 'cause-

Dr. Rangan Chatterjee 1:08:57 Yeah

Dr. Ayan Panja 1:08:57 ... it's so kind of, um, graphic. But, um, it-- Yeah, it's a great tool. You know, it's, it's no different in a way to, to a therapist or a doctor listening to a story or just sort of plotting it out really. There's nothing fancy or wacky about it, but it's just a, it's a great tool 'cause you can see it, and then it gives you something to work from.

Dr. Rangan Chatterjee 1:09:16 Mm-hmm.

Dr. Ayan Panja 1:09:16 Um, so I'm, I'm a real fan of it. I don't do it very often now 'cause we don't get the time, sadly, in the, the world that I'm in. But, um, but it's a great tool, and I do think people should do it for themselves and, and keep adding to it, you know. So, um, yeah, it's almost like a, [chuckles] it's almost like a retrospective vision board 'cause it's sort of what's happened in your life, you know? But... [chuckles]

Dr. Rangan Chatterjee 1:09:37 Yeah. Yeah. And, and I think, you know, I think these tools give the reader and give your patients agency. You know, they, they, they really feel, "Oh, man, I get it now. I get it."

Dr. Ayan Panja 1:09:50 Mm. Mm.

Dr. Rangan Chatterjee 1:09:51 And, and when, when a patient is bought in, when a patient-

Dr. Ayan Panja 1:09:53 Mm

Dr. Rangan Chatterjee 1:09:53 ... gets their story, that's-

Dr. Ayan Panja 1:09:56 Yeah

Dr. Rangan Chatterjee 1:09:56 ... where the magic starts to happen because then they're, they're really, in my experience at least, super motivated to do something about it-

Dr. Ayan Panja 1:10:03 Yeah

Dr. Rangan Chatterjee 1:10:03 ... 'cause they can see it. They go, "Of course I've ended up like this because of A, B, and C. Now I wanna take charge and make some different-

Dr. Ayan Panja 1:10:10 Yeah

Dr. Rangan Chatterjee 1:10:10 ... choices and see if I can change the outcomes."

Dr. Ayan Panja 1:10:13 The-- I, I think the other thing that, that really helps is there's something in the book that I call the drawstring effect, and it's, um, you know, it, it's basically this tightening up that happens once you sort of... So with Amelia, she's a really good example of this. You know, just changing one or two little things makes everything in your system work better. And once you start feeling that it's working better, you stick to it more. It, it-- Do you know what I mean? It's just, it's just an am- It's such a powerful thing. Um, but that, you know, that requires, you know, going back to the beginning of the book, the first two bits are on biology and behaviors. And, and the reason I do that, I call it the foundations, that section, because if you don't really-- If I don't-- You know, I'm not a particularly structured person, and I'm not very linear, but I realize that people want some substance. And if you don't kinda get those two things, if you don't understand your behaviors and how to change them, you won't be able to kind of help yourself. And if you don't quite get that symptoms come from systems, which is... That whole first bit is about systems biology, you know, just a kinda 101, and I think that works really well. And then, then you see, you know, once you lay it all out in the health loop, you think about your typical day, how, what, when, and then you can sort of almost write out your own lifestyle prescription. You know, it's, it's, it's really simple.

Dr. Rangan Chatterjee 1:11:34 Yeah. It, it, it really is. I, I thought Amelia's a great example.

Dr. Ayan Panja 1:11:39 Mm.

Dr. Rangan Chatterjee 1:11:39 Let's go to a different example-

Dr. Ayan Panja 1:11:42 Mm-hmm

Dr. Rangan Chatterjee 1:11:42 ... because, you know, as you're making the case, every single one of us can use that health loop-

Dr. Ayan Panja 1:11:51 Mm

Dr. Rangan Chatterjee 1:11:51 ... to identify what's going on in their own life.

Dr. Ayan Panja 1:11:53 Mm-hmm.

Dr. Rangan Chatterjee 1:11:54 So, you know, there's so many examples in the book.

Dr. Ayan Panja 1:11:58 Mm-hmm.

Dr. Rangan Chatterjee 1:11:58 Uh, I, I quite like Janine.

Dr. Ayan Panja 1:12:00 Janine, yeah. So really interesting case, and I, I... One of the things I should say is that how I picked these cases, um, is they're, they're based on the things I hear most commonly as a GP, you know. So over the last twenty or so years, um, the, the, people's health wishes, I've flipped them in a way, so tired all the time. You know, the, the, the health wish that that person wants, like Amelia, is they want more energy, you know. And Janine's case is one where her wish was that her memory was better. So she was struggling with her memory. She's like a, in her late forties, lovely lady, um, three kids. Background was that one of her-- her son had basically had, um, leukemia a few years ago, and that had left her sort of on high alert. She works really hard in a hospital and came to see me with fatigue and brain fog. Her memory was failing her, so she'd forgotten to do certain key tasks at work, which is really unlike her 'cause she's very reliable. And the background is that her dad has Alzheimer's, and so she was very worried that this was the start of that. Someone who also, for lots of reasons, had never, never exercised. She had a bad experience at school with a teacher, a PE teacher, which had sort of Shamed her somehow about sports, and so had just never done any physical exercise-

Dr. Rangan Chatterjee 1:13:30 Mm

Dr. Ayan Panja 1:13:30 ... ever since then, and had a really sweet tooth, and that was also quite interesting. Her sweet tooth arose from, um, a family funeral, and she remembers, you know, her uncle dying and a lot of her extended family coming round to the, her family home, and her and her cousins kind of snacking on sweets, and it was a source of comfort for her. And as a result, as we know, a lot of childhood kind of behaviors carry into adulthood.

Dr. Rangan Chatterjee 1:14:01 Mm.

Dr. Ayan Panja 1:14:01 She was someone who was just trying to kind of cope as best as she could with, you know, sweet milky cups of coffee to keep her going all day, and had just run out of resources. She'd, she'd even had a brain scan because she was so worried about her memory, and she works in a, in a hospital environment anyway, so had managed to arrange that. Nothing on the brain scan to worry about. She was a bit broken because she, you know, single parent, three kids. Her mom helps out a little bit. Really ni- nice lady. And what was interesting was, um, what laid out in her health loop were, were those things. Da- the, the genetics bit was her dad has Alzheimer's. Her diet, high sugar, you know, um, um, a little bit of stress around her son 'cause she worries about him a lot, you know? And actually if you've ever had any kind of experience like that, you know, a child with leukemia who suddenly gets a fever, it's a, you know, you rush straight into hospital pretty much, you know?

Dr. Rangan Chatterjee 1:15:00 Mm.

Dr. Ayan Panja 1:15:00 So she's always on high alert about him. And nev- never done any exercise, um, at all, you know. So those are the main things in, in her health loop. Where do we start with that? Well, you know, she's busy. Her typical day means that she gets home, has to make dinner for the kids, help them with homework, all that sort of stuff. And, you know, part of me was thinking, you know, she, she's sort of in her mid-40s. Could she also be perimenopausal? Possibly. Did a load of bloods, and actually it showed that she was pre-diabetic, so, which doesn't, doesn't s- didn't surprise me, but it really sort of slightly scared her, I think, you know, because, you know, especially, you know, she wanted to be around for her kids, and once you sort of realize that you might be on, on the journey to a particular disease, you, you want to take steps to stop that. So the first thing we, we sort of agreed was changing the how, what and whenever eating. That was definitely gonna be quite a big part of this. And also the fact that she's, you know... Exercise. Tell me a bit about that. You know, why, d- could you imagine yourself ever doing any exercise? And she's like, "Well, I just, it's just not, I don't wanna join a gym. I don't wanna..." You know, and sh- and, and actually the, the thing that absolutely worked brilliantly for her was something called Couch to 5K, which is an NHS app. It's absolutely brilliant. It starts really gently with walking and builds up to a five-kilometer run. So there were, there were all these things going, you know, in tandem with each other. Um, and she found it hard. I mean, she wasn't massively... She was motivated 'cause she knew she had to do, you know, something, but she found it very difficult, particularly if you've got a very sweet tooth. Anyone with a sweet tooth will know it's really not easy to suddenly go from having a coffee with two sugars to a coffee with no sugar. It just doesn't taste right to that person 'cause your taste buds are used to the s- the sweetness. So for her, you know, something called the IDEAL framework, which I mentioned at the beginning of the book, is, is what she used. So, you know, literally sort of identifying what she wants to do, that's I. D is defining what it is that she needs to do. E is engaging, A is activating, and L is looking back and patting yourself on the back saying, "Well done." And you know what? She managed it. She did the Couch to 5K. She struggled a little bit with the sugary foods, but the more she did it, the better she felt.

Dr. Rangan Chatterjee 1:17:34 Mm.

Dr. Ayan Panja 1:17:34 And bit by bit, her brain function got better, um, and her fear, which was actually, "Look, you know, does this mean I've got Alzheimer's?" Um, what's amazing about systems and symptoms is that all of the interventions that she's taking to bring her blood glucose level down also work to prevent Alzheimer's, you know. And, and, and, you know, I don't know whether she's gonna develop Alzheimer's in her lifetime, but if she does, hopefully it'll be 10 years later than she would've done, you know. And it's the same with diabetes. You know, we're, you know, we're all gonna get old and die at some point, but, you know, when, when your quality of life and when your symptom is meaning that you, you know, in her case, you know, the brain fog and the, the memory issues were so bad that they, that it's affecting your work and, you know, you can't function, you, you know you've gotta do something. But it just worked a treat with her, you know, and just laying those things out was, was the key.

Dr. Rangan Chatterjee 1:18:33 It strikes me that these approaches, I mean, you've shared two cases so far.

Dr. Ayan Panja 1:18:41 Mm.

Dr. Rangan Chatterjee 1:18:41 I know there's a ton of cases [laughs] in the book, which, you know, people are gonna be able to see themselves in-

Dr. Ayan Panja 1:18:48 Mm

Dr. Rangan Chatterjee 1:18:48 ... at least one of those cases. I think that's what's so clever about it. People are gonna go, "That's me. Wait a minute. That's exactly what I've got." This is not the typical approach. It's certainly not the approach that we're taught at medical school, and it's still not the typical approach that most doctors will use with their patients. And again, it comes down to this symptoms versus systems. We in medicine typically will practice symptom-based medicine. What's the symptom? What's the name for it? What's the disease label? What's the treatment? And again, as we mentioned, that has value. But certainly in my experience, Ayan, I, I, I wonder your view on this. The vast majority of what we now see, it, it doesn't-- you know, that conventional approach just-

Dr. Ayan Panja 1:19:38 Mm

Dr. Rangan Chatterjee 1:19:38 ... doesn't work that well. You know, what, what's your experience with that? And, and I guess following up from that, when did you realize you had to do something differently if you were gonna truly help your patients?

Dr. Ayan Panja 1:19:50 Hmm. Yeah, I, I think I realized that we had to do something differently many years ago because, you know, the model of, you know, trying something where you don't really know what's going on, hoping that it sticks, you know, I, I, I knew that it may or may not work, and you use that sort of Bayesian thinking of, it might be this, but I don't really know. Um, so that realization was many years ago. And, and actually what you say in a way, um, is, is nowadays only partly true 'cause I think the awareness is there. So whatever we wanna call it, the, the lifestyle medicine movement, you know, is quite big. But even within that, my, my issue is that it's not really focused enough on the individual.

Dr. Rangan Chatterjee 1:20:34 Yeah.

Dr. Ayan Panja 1:20:34 There's very much this kind of tick box approach as in like, well, you know, um, hey, you know, exercising for X number of minutes a week's meant to be good for you. Yeah, and yeah, we know that. But is that gonna work for you? And if it doesn't work for, you know, someone like Janine who's never exercised, just that isn't gonna be very helpful for her. You know, it's, it's got... it's much more nuanced. And I think you, you've gotta sort of start with the person, which is why I think this book's gonna help people 'cause it's about them. It's about their story. It's not about what's out there 'cause there's lots of that stuff.

Dr. Rangan Chatterjee 1:21:12 Mm.

Dr. Ayan Panja 1:21:12 We kind of, you know, if you've got, y- you know, resources are, are quite easy in a way. A- and but, but, but actually knowing what's gonna work for you is the hard bit. For, for the practitioner as well, you know. Do you know what I mean?

Dr. Rangan Chatterjee 1:21:26 Yeah, I think, uh, I think just following up from that, I kind of feel that a lot of the time we as humans are drawn to our kind of favorite area, you know. So-

Dr. Ayan Panja 1:21:37 Yeah

Dr. Rangan Chatterjee 1:21:37 ... you know, some people are foodies, right? Some people are, you know, very careful about their diet. They like to try and eat well.

Dr. Ayan Panja 1:21:45 Yeah.

Dr. Rangan Chatterjee 1:21:45 So if they're gonna have any health complaints, and they feel that the way that they're living their life-

Dr. Ayan Panja 1:21:52 Mm

Dr. Rangan Chatterjee 1:21:52 ... is contributing, they may feel, you know, I'm gonna go straight to my diet. And actually, I found that a lot of the time, hey, your diet's already really good. You know, that five percent improvement in your diet which you're trying to make with all that effort, I don't think it's gonna do much for you because you're neglecting the chronic stress in your life or the fact that you're sleeping five hours a night. And I think that's what your health loop does really nicely, is it, it just shines a light on, oh, these are the areas I need to work on.

Dr. Ayan Panja 1:22:19 Exactly.

Dr. Rangan Chatterjee 1:22:20 Right?

Dr. Ayan Panja 1:22:20 Yeah.

Dr. Rangan Chatterjee 1:22:20 Doesn't matter what the influencer on Instagram said or, or, you know, what my friend said. Actually, no, these are the two or three key areas-

Dr. Ayan Panja 1:22:28 Mm

Dr. Rangan Chatterjee 1:22:28 ... in my life that if I put a bit of attention there, they're gonna work. So I think that's worth highlighting. The other thing I like about the health loop and the way you've written about it is that this is an iterative process. It's not just a, a one-hit, is it?

Dr. Ayan Panja 1:22:42 No.

Dr. Rangan Chatterjee 1:22:42 It's something you can do, make some changes, and you redo your health loop. So maybe can you speak to that a little bit?

Dr. Ayan Panja 1:22:48 Yeah. That, that's a really good point. Um, and, and it is iterative. The, the first thing I would say is that, you know, anyone who's been through this process, and I know I'd say maybe 100 people have done this kind of process, either through, you know, myself or themselves or, you know. And, and anyone who's made changes to their health by, by analyzing their routine and, and, and laying things out will know how great it feels to feel better. The problem is twofold, really. One is that we're, we're all getting older, you know, and that means [laughs] that the expectation bar gets raised so high by the, by often the person themselves thinking, "Yeah, you know, I, you know, I, I feel fantastic, but I wanna feel even better," you know? And then it's like, well, hang on. Compared to how you were feeling six months ago, you, you are doing amazingly well. But some people wanna go to that next level, and I think at that point, it then is a case of really drilling down, you know, the type of apple that you eat rather than just eating an apple, you know. But hey, that's fine, you know. Horses for courses. Um, but, but you, you can, um, do, do, um, do the health loop again and again and again and keep refining it, and you, you'll just find, you know, other things that just pop up where you think, oh, you know what? Actually, like, the way I was doing press-ups, you know, was making my shoulders ache, and I've just modified it a little bit by splaying my hands or, or just, just, just little micro... I call them tweaks in the book, you know.

Dr. Rangan Chatterjee 1:24:16 Mm.

Dr. Ayan Panja 1:24:16 And they're quite important, um, sometimes. You know, things starting to kind of fade.

Dr. Rangan Chatterjee 1:24:22 Yeah.

Dr. Ayan Panja 1:24:22 Yeah. So it, yeah, it is iterative. You can just do it again and again and again and again, hopefully just feel better and better.

Dr. Rangan Chatterjee 1:24:28 I wanna talk about the concept of balance, and why this has come up for me is there's a little story in the book where you talk about one of your mates who lives in Asia, and you talk about his wonderful morning routine, but the fact that he finishes it off with a cigarette.

Dr. Ayan Panja 1:24:46 Yeah. [laughs]

Dr. Rangan Chatterjee 1:24:47 So perhaps you can share that story and, and, and share your conclusion from that, 'cause I think it really speaks to balance.

Dr. Ayan Panja 1:24:54 Yeah. Um, yeah. It's, it's, it's so funny this because he was telling me what his... what he does every day, you know. Like, not, not... it wasn't a consultation. It was just a s- sort of a normal conversation about whatever, and it was like, "Oh, you know, in the morning, I get up at 5:00 in the morning. I stretch, you know, and then I go for a run. I come back, and I drink a load of, like, you know, fresh filtered water. Um, and then I either do some yoga or some meditation, and then I sit on my balcony and I have a smoke." And I'm like, smoking a cigarette, you know, nothing else. But... And I'm like- What? You know, it was like this record scratch thing. It, well, I wasn't expecting it. I was like, "Oh, I thought you were gonna say you have, like, a fresh fruit platter or something," you know?

Dr. Rangan Chatterjee 1:25:41 [laughs]

Dr. Ayan Panja 1:25:41 Which he does anyway, but, but it just didn't fit. And, and, and I go... And he, and he goes, and he even said to me, he goes, "Look, it, it's therapeutic." I'm, I'm literally just sort of sitting there just looking out into the desert.

Dr. Rangan Chatterjee 1:25:52 [laughs]

Dr. Ayan Panja 1:25:52 And I'm like, "Right." I go, "I wouldn't say it's therapeutic." But the point was, it's to do with context, this, because, you know, if you, you know, think about, uh, your average smoker, they're kind of rushing out in the rain, you know, 'cause you're not allowed to smoke indoors in, certainly in the UK, and, and you're going outside and sort of, like, struggling to light it up and kind of, like, having a couple of puffs thinking, [laughs] "Oh no, I've had my break. Now I've got to get back up. Oh, the lighter doesn't work," whatever. And, and that, you know, I'm, I'm not, I'm, you know, I would never encourage anyone to smoke, but the point is that the context of him smoking, even though he's only smoking one cigarette a day, which is mechanically and physically probably doing him some harm, is, you know, in terms of the rest of his habits, you know, the effect is likely to be fairly minimal. You know, as in, I guess the, what it boils down to, a real hardcore scientist would go, "Oh, we want to study the effect of having one cigarette a day," is, is how a scientist would look at it. But, um, and that, that is totally different depending on your genes and how you react-

Dr. Rangan Chatterjee 1:27:00 Mm

Dr. Ayan Panja 1:27:00 ... to cigarette smoke and toxins and stuff like that, so in itself is, is slightly flawed 'cause you, you just don't know with anything what the effect of something's gonna be on the individual. But I guess the point being that you don't have to be perfect, and no one is. I mean, I myself probably do about 60% of what's in my own book, which isn't that high, you know? And, and, and why that doesn't matter so much is that if we go back to the very beginning of this conversation and you asked me about my tips, just doing hydration better will make you feel X percent better. So that's 1 out of about maybe 10 things that come up from your health loop. Do you know what I mean?

Dr. Rangan Chatterjee 1:27:42 Mm.

Dr. Ayan Panja 1:27:42 So actually, it's that whole drawstring effect. The more you can do, the better you feel, and there is a threshold. And, you know, you might say to me, "Well, hang on. What, what's in your health loop now, and what are you doing?" Well, at the moment, touch wood, not, not very much. Sleep actually is definitely not great, but as in I need to address it. It's not that I don't sleep well. I'm just getting to bed late-

Dr. Rangan Chatterjee 1:28:03 Mm

Dr. Ayan Panja 1:28:03 ... and that's having an effect on me craving certain foods and, you know, all that sort of stuff the next day. Um, so I do need to do some work, but the, the time I'll really pay attention is when things slip a little bit more and I think, hang on a sec, I, mm, I really need to kind of, you know, think about my environment, you know? Environment's a massive piece, you know, and a lot of people don't realize that they've got a load of mold in their bathroom, which is making them cough or whatever. You know-

Dr. Rangan Chatterjee 1:28:31 Mm

Dr. Ayan Panja 1:28:31 ... there, there are things that will just pop out. So, so yeah, balance is really key.

Dr. Rangan Chatterjee 1:28:36 Yeah.

Dr. Ayan Panja 1:28:36 You know, you can't do everything perfectly, and, you know, I, I, I... It's not, it's not possible, 'cause none of us are perfect.

Dr. Rangan Chatterjee 1:28:43 Yeah, I think that's a, a really important message actually. I think it's very empowering for people because we are, all of us are bombarded with more and more things that we could do. Uh, and I'm, you know, very, very aware of this. You know, having a health podcast, you know, posting regularly health tips on social media, you know, I'm aware of this that, you know, there's a lot of information out there. You don't have to do it all. Um, coming back to the health loop again, just to reiterate, I think what's great about it is it will help you identify which area do you need work in. So for example, if you're already moving your body well for you in the context of your goals and the context of your life, yeah, you can see a new Instagram post from someone about the benefits of this, you know, latest exercise or this machine or that, and go, "Yeah, okay, great, but I'm okay in that part of my health loop."

Dr. Ayan Panja 1:29:40 Yeah.

Dr. Rangan Chatterjee 1:29:40 "I don't need to worry about that. I can read it. I can enjoy it. I can absorb it, but that's not for me right now. What is for me are these two things that I've identified."

Dr. Ayan Panja 1:29:50 Yeah.

Dr. Rangan Chatterjee 1:29:50 You know, which I think is really powerful.

Dr. Ayan Panja 1:29:52 Yeah.

Dr. Rangan Chatterjee 1:29:52 And in that example that you mentioned of your friend who lives overseas-

Dr. Ayan Panja 1:29:58 Mm

Dr. Rangan Chatterjee 1:29:58 ... you know, it reminds me of, of a, of a couple of patients who I saw in the past who would have a sugar in their coffee on a Sunday morning. But I remember thinking, hey, you know what? You are thriving. You've made all these phenomenal changes. Your diet is absolutely incredible now.

Dr. Ayan Panja 1:30:21 Mm.

Dr. Rangan Chatterjee 1:30:21 You move regularly. You're sleeping well, but your vice, if you will, is this-

Dr. Ayan Panja 1:30:27 Mm

Dr. Rangan Chatterjee 1:30:27 ... you know, cappuccino on a Sunday morning with one sugar in it. And again, you know, like you said with smoking, I'm not encouraging people to do this, but I do think sometimes we need to take a step back and go, well, in the context of everything else in that person's lifestyle, is this really a problem? And, and for this particular individual, it really wasn't.

Dr. Ayan Panja 1:30:48 Mm. Yeah.

Dr. Rangan Chatterjee 1:30:49 Do you know what I mean?

Dr. Ayan Panja 1:30:50 Yeah, yeah.

Dr. Rangan Chatterjee 1:30:50 It was almost... Potentially, it was the vice that allowed everything else to work.

Dr. Ayan Panja 1:30:55 Yeah. Yeah.

Dr. Rangan Chatterjee 1:30:56 You know? And that's, that's real-life medicine. That's kind of getting away from the-

Dr. Ayan Panja 1:31:02 Mm

Dr. Rangan Chatterjee 1:31:02 ... the textbooks and the, the ideal stuff and the scientific research papers. It's like, well, this combination is working for this person. And I think this is a, a pretty good place to sort of start finishing off this conversation because I feel that's what your book does so brilliantly, I think, is it helps people personalize the changes that they need to make, that they want to make- They're empowered to kind of do it for themselves, right?

Dr. Ayan Panja 1:31:37 Yeah.

Dr. Rangan Chatterjee 1:31:37 It's not like, oh, follow this because I've told you to do this. It- it's a very different approach, which I think is gonna be much more effective for people.

Dr. Ayan Panja 1:31:46 Yeah, I think, I think, you know, I, I really do hope it, it does that, you know? I mean, in, in essence, what the book does is it takes you and your life, you know, not anyone else's, you as an individual, all the elements of it, and this is why it's all about understanding yourself, you know? And it lays out anything that might need addressing through the health loop. You think about your typical day, you lay out your timeline, which looks at your past medical history and your life to date, and then you look at the bits that jump out from the health loop and apply how, what, and when, if that needs doing. There are other tools in the book called Drill Down and Diary Up. You may need those, you may not. And what that all enables you to do is write yourself a lifestyle prescription, and that is just a very simple list of things that will change your health for the better, given what you've already done with all this info that you've got. And that's it, really simple.

Dr. Rangan Chatterjee 1:32:53 Simple, but very, very effective. I think you did a fantastic job with the book. I think it's gonna help so many people. If people wanna follow you online, where would you direct them to?

Dr. Ayan Panja 1:33:04 Um, Instagram, Twitter, LinkedIn, and Facebook. I've got a Facebook page as well.

Dr. Rangan Chatterjee 1:33:09 Okay, fantastic. And you've also got a podcast. You wanna tell anyone about your podcast?

Dr. Ayan Panja 1:33:12 Oh, definitely. Well, that... The podcast really is what this book does, I think, and the podcast is called Saving Lives In Slow Motion, and it's a bite-sized podcast, which is just me. There's no guests, and it's, like, 10 to 15 minutes on various topics that kind of affect us in our lives and I think will be interesting.

Dr. Rangan Chatterjee 1:33:34 And, uh, final question. Um, a lot of people, as you've hinted at throughout this conversation, are really struggling. People are struggling with stress, the state of the world, the state of their own lives. We've covered so many tips today. There's a ton of tips in your book, but if you were gonna leave people with one final tip, one thing to think about, what would it be?

Dr. Ayan Panja 1:34:01 I would say just be in the moment. Live in the moment, in the now, and savor everything that you're doing because life's short, and you just don't know what's gonna happen tomorrow.

Dr. Rangan Chatterjee 1:34:18 Ayan, thanks for coming on the show.

Dr. Ayan Panja 1:34:20 Thanks for having me. [upbeat music]

Dr. Rangan Chatterjee 1:34:21 If that conversation resonated with you, here is another incredibly powerful one that I really think you're going to enjoy.

Speaker 1:34:27 Addiction is the most human thing there is. All addictions, they're attempts to gain pain relief, emotional pain relief for something or another. Then this whole society is so expert at selling us stuff to fill those holes temporarily. This is the whole ethic of this culture