The Toxic Metabolic Effects of Stress (w/Dr. Ron Sinha)

– Hey, what is up, ZPac? It’s ZDoggMD, Dr. Zubin Damania. Okay, I brought homeboy back, and I don’t often do that with guests. There’s just a handful of guess we’ve brought back because they’re so awesome that they need to come back, and my boy Dr. Ronesh Sinha, he goes by Ron, Ronnie James Dio, if you’re nasty, is a Internal Medicine physician, Director of Corporate Wellness at the Palo Alto Medical Foundation which is my former organization. I had him on the show about two years ago talking about South Asians, in particular, and their particular brand of metabolic illness, diabetes, polycystic ovary syndrome, et cetera, and that was such a great show and then I moved back to the Bay area, and I’m like we’re neighbors, come by, be on the show, and then I heard him recently on Peter Attia’s podcast, who was on our show as well, talking about all the things, and I said we need to go deeper into the quote-unquote touchy-feely stuff that Peter didn’t have time to dig into. So everybody, welcome back to the show Dr. Ron Sinha. What up, Ronnie James?

– Hey, what’s going on? I hope to sequel is as good as the original.

– Dude the sequels are always better, we know this. I mean look at Superman II. Do you remember that one?

– We are doomed

– You will kneel before Zod

– [Ron] Oh great, nice .

– Actually, the most poignant moment in that movie was when Superman he’s, you know, he’s back to being Clark Kent, his powers have been given up, relinquished, and he’s just humiliated in that little bar in Alaska. He gets punched and beaten up, and he’s bloody, Lois Lane has to drag him out of there, I’m like you know, this is true human vulnerability. And finally, Superman feels like us.

– [Ron] Yes, that was empowering.

– Exactly, so, you know, what I want to talk about today is there’s so much stuff, right? And I actually put it out to the fans, I’m like what do you want me and Ron to talk about? Because you are, you’ve done something remarkable. Internal Medicine, you could have been a cog in a machine of corporate medicine. And instead, and we worked in the same, in the same place. It’s very easy to just go in and punch the clock, do your job, click the boxes, complain, go home, take it out on your kids, go to bed, repeat. It’s very hard now, and there’s so many expectations, but what you did is you saw something in your patient population, because it resonate with you because you’re Indian, you’re Bengali, and you saw this pattern of disease, and a pattern of suffering, more specifically, that instead of saying oh yeah, this just seems to happen and Indians, South Asians, we just deal with it, we do the same medicine we do for everyone else, you actually took it on yourself to explore it to a degree where you are now a national and international expert on metabolic disease, on stress, on how to manage this in this population, and how did you even get down this route?

– Yeah, it’s a great question. I mean, I was seeing this disorder so rampant in my patient population over a decade ago, and I think what really hit was number one, I had no practical ways to help anyone because there were no good resources out to really intervene and say, like if you’ve got any Indian vegetarian with metabolic syndrome, did you give me a handout, you know, with the Mediterranean Food Pyramid, or what do you give them? A low fat diet, American diet? There’s just so many limited options out there. So I decided that point that we need to start creating some resources to really engage these individuals. So the first step is really finding something that resonates, but also finding a gap. And there’s a huge gap. You can find resources maybe for other cultures, but there was nothing really for South Asians at that time.

– But why, what’s going on with South Asians? What were you seeing?

– I mean, basically, what I was seeing is you know, in med school, if you remember us doing case studies, right? When you’d see a heart attack case study, it wasn’t typically a 30 year-old engineer that works at, you know, that works in a sedentary profession, it was kind of unheard of. So I was seeing a phenotype that was so different than what we learned about medical school that it was shocking to me. You know, just seen people coming in that early with chronic illnesses that I thought would present decades later, so that kind of hit a light bulb already. Then I dug into the research at that time and I really had trouble finding really good resources that helped highlight that problem. So, and you know, if I’d saw a one-off, you know, in the beginning it was like okay, maybe this is an exception but this was becoming a rule. I mean I was seeing people coming to my clinic, one after the other, and every single individual that walked in and had some sign of insulin resistance. You know, high triglycerides, pre-diabetes, some sort of manifestation there. So it was literally an epidemic that I was seeing in my office.

– And you know, this was not publicly discussed. So this is the thing where like I remember training at Stanford in the late 90s, early 2000s, and you’d be on the CCU, and there would be a huge number of young Indian man. And then I practiced at Palo Alto Clinic with you and I would rotate through Fremont Washington Hospital, young Indian man with LAD disease, multivessel disease, going for cabbage, and they’re like 30 and 40, they’re engineers in these top Silicon Valley organizations, and I’m like something’s going on, and you know, it’s funny, all the Caucasian ER docs, they’d be like oh, we got another Indian guy, better just like basically admit him I mean, they recognized the pattern. They didn’t realize what is was. Now, you said the term insulin resistance. Can you explain for people in the audience that don’t understand wat that means because even people like Peter Attia, it can get really deep into a rabbit hole. But how do you think or explain your patients about insulin resistance?

– Yeah, at the highest level, what I would say is you know, insulin is basically a hormone in the body that helps triage different nutrients in two different sites so specifically for consuming carbohydrates, insulin will help triage that glucose from the carbohydrates to different tissue sites. If we focus at one, you know, the way I sort of use this in lectures and in my book is think of sort of glucose, for example, as being a car in the body, and we’ve got three parking lots, okay? Three major parking lots, muscle, liver and fat. And in an ideal situation, when you have glucose in the bloodstream, that glucose car that’s zooming around, you want to push that glucose car into the muscle parking lot so the muscle can burn that for energy. The way the car gets inside that lot is by using a parking pass called insulin. Insulin will open up the door so glucose can get inside. Now when we say somebody’s become insulin-resistant, what happens is basically, your body is producing the parking pass, but that muscle parking lot is not responding to the pass. You’re putting a pass into the gate, and the muscle is basically not opening up the gate. So then you got the spillover glucose, it now has to go into different sites. So number one, it might go towards your fat cells and your fat cells can convert that glucose into fat, adipose tissue, and we develop obesity as a result of that. It can go to your liver, and your liver can take that glucose and also turn it into fat in a form call triglycerides. And then the body tries to compensate for this problem by producing even more insulin. So individuals that have insulin resistance, we have this condition called compensatory hyperinsulinemia, they’ve got very high insulin levels, and on a daily basis, if you have high insulin levels, you’re just more prone to obesity. You think of carbs, you’re gonna gain weight. So it’s basically the initial insulin resistance that’s a problem, but then it’s like compensatory elevation of that parking pass that causes even more issues. And aside from insulin causing obesity, insulin also causes vascular dysfunction, so it can cause inflammation of the blood vessel level, it can lead associated conditions like PCOS, and gout, and everything else, and that’s really coming from excessive amounts of insulin. As you know, if we didn’t have insulin, we’d die, but just like so many things is all that moderation. We want insulin to be at the right level.

– So this is a very important distinction, and again, insulin resistance is bandied around a lot, and you can go deep into the rabbit hole of what causes it, is there a chicken-and-an-egg thing, what’s the ultimate meaning of it? People like Dr. Jason Fung have postulated that this parking lot of muscle doesn’t let glucose in not because there isn’t enough insulin or that the insulin isn’t opening the gate, but that the parking lot is full. And so that’s one theory, there’s other theories, but the bottom line is you end up with this vicious cycle of rising insulin levels, and insulin itself being harmful, in this sense, like you said, effects on the vasculature, it’s anabolic, it’s a growth hormones, whether there’s questions about tumorigenesis and cancer, and what you were seeing in the South Asian population, the East Asian population too, and what you were seeing is kind of like a test case, almost like this is the guinea pig group that has the genetics that tends to be insulin-resistant if you treated it wrong. Whereas in India in the old days, people are walking everywhere, they’re squatting, they’re eating a high-carbohydrate diet, but they’re exercising a lot, and it’s not a lot of processed food and other stuff, and so they were able to do fine. Now you take those same people and you put them in the western diet, and everything goes haywire, presumably due to insulin resistance as the primary cause. Is that correct or am I missing anything?

– I would say so, absolutely. And you’re so right, the parking lot analogy was a way for me to sort of simplify the understanding, so common people can learn that, but you’re so right, I actually don’t think the parking lot is the exclusive cause of insulin resistance. There’s multiple theories, there’s free fatty acid toxicity of the receptor level, there’s so many ways we can go, but in my job where I just want to get people healthier, I don’t want to add confusion to the conversation. I need the lowest hanging fruit that’s gonna help sort of solve this problem, and then we can dig deeper if we find certain nuances to that. So I think, just like you know the days of the low fat diet, unfortunately, that didn’t go very well, but we had a simplistic model of fat raises dietary cholesterol, aka causing plaque, and this leads to heart disease, you know, hopefully, we’re not being a little bit careless about oversimplifying the model, but I think some simplification helps people understand that this is why an healthy vegetarian i.e. somebody from India who’s eating a lot of carbs can develop rampant diabetes and heart disease without ever touching saturated fat.

– Hmm, and this is a key point, a lot of these folks are vegetarians, and you would think oh, you know, that should protect them against heart disease, diabetes et cetera, especially if you believe the vegans, but the difference here is that we have a lot of carbohydrates and an insulin-resistant tendency population and you said something very important early on, the liver is one of the parking lots for glucose, it’s fat, liver, muscles, the big ones, correct? The liver actually turns excess glucose or fructose, depending on what you’re eating, into triglycerides, which are a kind of fat, and they’re circulating in the blood, so people with this metabolic syndrome can have elevated triglycerides that aren’t due to fat consumption, they’re due to carbohydrates consumption.

– [Ron] That’s exactly correct, yep.

– And did I ever get taught that properly in school? I don’t remember being taught that properly. I’m sure it was spelled out as a metabolic pathway, but all we heard was fat begets fat, and high triglycerides, you better lower the fat in the diet.

– Yeah, absolutely, and even when you, we see so many individual with fatty liver, and if you Google fatty liver and go to all the most established healthcare institutions, if you look at their handout, rarely any of them mention anything about lowering carbohydrates or sugar, it’s still focused on low fat. I think some entities were changing, but it’s always like the bottom bullet point on that list and so it leaves individuals confused, and on the wrong path.

– Right, so now you have this population of patients that you take care of specifically, but you do other things as well, which we’ll talk about, but let’s stick with the South Asian population, because I think it’s a good case study for what’s going on with diet, genetics, stress. So one of the manifestations of insulin resistance is frank diabetes, heart disease, cancer potentially, in fact you’re seeing breast cancer is younger and younger.

– I am, yeah.

– I know several patients, Indian women, they’re getting young, young, young thyroid cancers, breast cancers.

– Yeah, exactly.

– It’s really interesting. Do you think this is also related to insulin resistance or do you think there’s something else going on in the population?

– I think insulin resistance is one of the components, but I don’t think it’s necessarily the central one. You know, I kind of use these two terms interchangeably, insulin resistance and inflammation, which is are low-level activation of our immune system. You know, so our immune system should be an on demand system that helps heal injuries, protect us against infections, but when that thing is turned on at a low level hum continuously 24/7, it can activate all types of adverse processes, cancer being one of them. You know, in my work, I try to separate those two out so individuals understand that process, but they are so interrelated. Insulin resistance is intrinsically an inflammatory process and then inflammation can actually beget insulin resistance so the cycle can go in both ways, and when I look at individual patients and I take a detailed history and I look at lab values, often, there’s significant overlap between both. So you know, in many of my women, for example, they may not manifest with any specific signs of insulin resistance, all the typical criteria are not there, but I can see from their symptoms and some of their history that they’ve got a lot of inflammation that started a very early age. This might be simple things like eczema, chronic migraines, seeing some thyroid dysfunction early on, and this is not something we can very easily diagnosed. You know, people might say check is C-reactive protein or a sed rate, you know, one of these nonspecific inflammatory biomarkers, but really, a lot of it just comes from the history, just understanding that these are processes where the immune system’s probably working in overdrive. So when I look at women or I see patients in an early stage, I’m already, you know, we don’t want to think about cancer by the time we detect something on a mammogram, we want to think about what are lifestyle factors that might be contributing to this? You know, one thing I talk about with diabetes is don’t wait for prediabetes, you know? Catch it at pre-pre-diabetes. If you’ve already got an extra visceral abdominal fat, your triglycerides are mildly elevated, maybe even within the normal range, this is when we have to intervene. Same thing with cancer, where are the early signs of inflammation happening, so we can intervene as early as possible, and not which that screening mammogram to pick up on an abnormal mass.

– So true preventive care.

– Absolutely, yes.

– Looking at the root cause whether it’s inflammation, and you have to be careful because a lot of quacks online love to bandy around the term inflammation, right? But see, you actually take care of people who are actually inflamed, and there are markers, right? C-reactive protein, other markers that you can measure that then go hand-in-hand with this vicious cycle that we are calling insulin resistance, but it’s really a complex cycle. Now what’s interesting is in these young women in particular we’re seeing a lot of, and this was a big question when I put it out to the Z-pack, I was like hey, what do you want me to ask Ronnie James Dio? They were like well, ask him about polycystic ovary because it seems like it’s rampant. And my own personal story with that is I have a very close relative who I won’t name or say what their relation to me is to avoid embarrassment, because when they were young, we were growing up, you know, she had facial hair, and started to get obese after puberty, and irregular menses and moody and emotional, and all the stuff, and you know, as a relative, you know, we would all poke fun at her, and be terrible and vicious bullies, and I still have a lot of guilt about that, and a truth is when I look back at what this was, it turned out later she was diagnosed polycystic ovary. Same genetics, South Asian, feel terrible about it, doing great now, met four men, had babies, doing fine, but at the time, no one could understand. And there were so many young Indian girls who had facial hair and body hair and these signs that now we know was this syndrome, which you don’t even like to call polycystic ovary syndrome you call it something else which we’ll talk about, but it was so stigmatizing that now if we can recognize it for what it is, intervene on the root cause, we can actually help a lot of suffering. Can you tell us more about this?

– We should start a support group for guys that have a guilt over teasing girls that had PCOS. Really, I mean, it was amazing how even in our social circle growing up, there were a bunch of guys that teased girls that have facial hair and all the stuff, and we had no idea what happening, no awareness about this condition. So again, that’s such a great example of trying to, you know, you don’t want to wait till the hormones are out of whack. This is something you can truly identify very early on. So I tell parents ’cause I see so many generations of families in my practice, if you’ve got a daughter, she’s insulin resistant or has PCOS until proven otherwise. So you do everything you can to stay ahead of that condition as much as you can so–

– [Zubin] How do you do that?

– So you know, basically, the nice thing is, you know, again, when we learned about PCOS in medical school, we weren’t really taught that this is a reversible condition that’s primarily due to lifestyle changes, right? Do you remember any lectures?

– No.

– [Ron] Maybe you went to a better school than I did, maybe they taught better so–

– Where did you go to school?

– I went to Tufts.

– [Zubin] Dude Tufts is a fantastic school.

– I went to UCSF where they think they’re better than everyone, this is true, okay?

– Right. I thought maybe they taught you the right information.

– Oh no, no, no, what they taught us was it’s this typically irreversible but treatable condition, that we don’t know the etiology of it, but a lot of them actually have some degree of insulin resistance, and for some reason, Metformin helps.

– That’s exactly right.

– That’s what I was taught.

– Yeah, yeah, yeah, so again, it’s that whole spectrum. If early on, you identify, and this is so critical, at the earliest age, if you have a daughter, just making sure you’re keeping track of her physical activity, her diet and nutrition early on can make a big difference. Now, for those of you even planning to get pregnant, this is really where you can already start making a difference because as a mom, you know, and many of them on that I see that, you know, the pregnant women that I see my practice, they’re working very high-stress jobs, they have no time for nutrition, and what they’re eating at that time and their physical activity patterns is already gonna dictate what sort of glucose tolerance you know, their future infant is gonna have, basically, right? So if you can catch even at that stage, so I don’t think I really love doing is when I go to corporate wellness programs, they sometimes invite me to give talks to pre-pregnancy populations, so couples that are planning to get pregnant. That’s one you get hit at the most. If you can make them aware of these sorts of conditions and intervene then, I tell them treat pregnancy like an Olympic event. You want to train for that event, and not sit stagnant, stressed out, and eating the wrong types of foods ’cause it’s really starts in the intrauterine phase. So, intrauterine, you’re actually affecting the child’s glucose tolerance.

– That’s exactly right.

– Yeah, and that’s something that is a new understanding relatively, correct?

– [Ron] Yep, absolutely.

– [Zubin] ‘Cause I was never taught that.

– Yep .

– And I think the theme of this whole talk, Ron, is this is stuff that we were never taught. And, so this is why I’m such a Ron Sinha fanboy because you actually got woke enough to do something about it in your practice, and I know a lot of internist who just are either too busy or they’re too conditioned to actually go you know, could we be missing something big that is a different way of thinking about this? And now it’s starting, it creates its own momentum, and the fact that we have the internet and social media to actually take physician voices and amplify them in a good way is great. Now we have plenty of horrible Instagram influencers and other you know, quackopractors and others who are online selling us garbage, but there’s a lot of, and there’s a lot of great chiropractors, say, who are focused on you no pain management specific things, and they add a lot to the conversation, but with so much noise in the system that it’s great that someone like you is out there doing corporate wellness events ’cause those are people who need to hear it, they’re the most stressed out people on the planet.

– [Ron] Agreed, yeah.

– What are you telling young girls who, or parents of girls with PCOS on how to manage and improve their condition if they have it already?

– I mean the high-level message, I don’t do the, you know, necessarily the medication management, but I give them a nice piece of hope, basically, that this is something that is potentially reversible, that it is primarily lifestyle induced, and in many of the cases, when we see people make a proper lifestyle changes, we see a lot of those hormonal dysfunctions actually regulate, so I think that’s really empowering news ’cause a lot of parents haven’t really heard how much of a factor lifestyle really is for that. You know, obviously, there might be cases where you still have to use oral contraceptives, some degree of Metformin, but if earlier they can get that message and make the right sorts of changes, it’s huge. I don’t like you scare tactics, but I think it’s very important for the whole family to know that PCOS can lead to a higher risk of future heart disease and diabetes. I kind of present that in a gentle way so we’re aware of the landscape of what can happen if we don’t intervene now, but after we sort of set that stage up, we’ve got to give them empowering lifestyle choices they can make, and then give them things that they can track as they go along the way. If glucose is already a little bit off , if triglycerides are off, or body mass index or waist circumference is off, what are the things that we can do to make a change? And let’s monitor these monthly, every couple of months, stay on top of them. And you as a practitioner if you’re busy, and you don’t have to time to do that, just the fact that you as a doctor can acknowledge that this is potentially PCOS, and instead of just referring to a specialist like an endocrinologist, can I get a dietician or a health coach to work with them in conjunction with the specialist? So we have a lifestyle strategy that is as potent as a medication strategy as well. That’s the way to sort of take advantage of that knowledge.

– And see, that’s another thing that’s pretty woke for most internists. So most internist are Medicaid first, lifestyle’s never gonna happen. And I think that’s a sad capitulation. First of all, it’s a capitulation to our broken system which says we don’t have the time, the resources, the autonomy, the tools to actually help patients with lifestyle, but you said a few key things, health coaches, lifestyle nutrition, those kind of things. We can actually refer to that. We have to do it all ourselves. We take a lot on ourselves too, and this one thing that you had mentioned, it’s like you want to use scare tactics with the parents and there is an empowerment to saying this is a potentially reversible thing if you just do the right stuff, you can avoid these things that can be harmful. One thing that I wonder how you address is that sometimes, the parents are partially causative in this in that they create a lot of stress, expectations, maybe that the cultural dietary stuff is there, maybe there’s an acceptance, like oh, everybody in the family is hairy when they’re adolescent. I mean, we heard some of that in my family. Oh, you know, I had that when I was growing up. How do you sort of manage that?

– You know, you bring up such a key point because as much as we’re focused on diet and physical activity, the stress access, the whole family needs to understand that. And as we know, stress is intimately linked to sleep dysfunction. And there’s so much great science now showing what a direct link there is between sleep deprivation, poor quality sleep, and insulin resistance. It had such a profound impact. I know Peter Attia has talked about this a lot. I’ve followed my patients’ fasting blood sugars for a long time and correlated it with how many hours a sleep, but as we see teenagers who are stressed out, so now how do we connect the dots on emotions, behaviors and metabolism? The way we connected it is if you overscheduling your kids, if you’re telling them to take six AP classes, do piano, do math, do all of this, and then they come home and they’re supposed to do two hours of homework, what time are they going to bed? Probably midnight or 1:00 a.m. and guess what, that first half of the night is so critical for anti-inflammatory metabolic hormone production to really regulate your hormones that can influence glucose metabolism. So if you’re creating an infrastructure and environment and a schedule that’s pushing your daughter to go to bed that late, then it’s really an uphill battle. You can do anything you want with diet and physical activity, already we’re starting the day when we wake up, going the wrong way, so really important.

– Oh my God, so much to unpack on that, and I hate that word unpack. It’s such a douchie thotlier thing to say, but I’m gonna say it. So yeah, I heard you talking about this with Peter, we had Blair Duddy, a pediatrician on the show talking about sleep and how crucial it is and how are schools start too soon, we have too many expectations on these kids, particularly kids who are gifted. They’re cursed with high neuroticism, high expectations, big fear of failure, all kinds of stuff like that. What’s interesting is like if you, so there’s such a culture particularly in South Asians and Asian parents, and I know that we both know this from personal experience both being a parent and being parented by these people, that there’s nothing good enough. So if you tell these parents, you know what, the kid needs to get sleep because of glucose regulation and hormone regulation, then what they’re gonna do is they’re gonna go to the kid and be like get to sleep because the glucose, the glucose is you’re going to mess up. Here, watch this TED Talk on glucose.

– Yes.

– Right? And it becomes now it’s a competition for how soon you can get to sleep. Everything becomes gamified. Their stress level cortisol goes up, their sleep quality is bad, their fasting glucose goes up, they become more insulin-resistant, you know, how do you talk to these parents?

– You know, the key thing is, I think what you’re talking about is communication style with your children, right? And if we’re always top down and dogmatic about everything, then pretty much your kids are gonna push mute every time you open your mouth.

– Wait, is there any other way to be? because I mean.

– I know, right? Not the way we were raised, right?

– [Zubin] Not the way we were raised, yeah, yeah, yeah.

– But really, if you want to make a move with this, I mean there’s two types of kids that I’m seeing in Silicon Valley. Some will listen compliantly, they’ll nod their head just like you did right now, and they’ll be very quiet. And sometimes we think that great, that’s such a great kid, that kid is so polite, he listens to everything, but a lot of the time, these are the kids that are suffering the most because they have not developed the ability to actually express their emotions, or talk to their parents and share things. They’re basically working in a company where Mom and Dad are the boss and I’m basically ground-level work, right? Then on the other hand you’ve got more of a conflictual relationship with the parents where there’s a lot of adversarial things going on, and that’s also not healthy because anything the parents say the kids aren’t gonna listen to. So we gotta find some middle ground where we can actually optimize communications, develop trust in the system, so then if you do give a little pearls of advice, and then your mimicking those pearls by you not staying up till two in the morning looking at your phone, then those are the things that can create more shifts.

– Oh man, okay, let’s keep going down this path because this to me as a parent, is now so fascinating, and we talked about the book Coddling of the American Mind with Jonathan Haidt, you talk a little bit about it with Peter. I want to go deeper down this hole of parenting because particularly now, okay? We have this whole idea that were over-parenting the kids and we’re coddling them and we’re keeping them overly safe, they’re not taking risks, they’re not having unstructured free play, all these other things, and we’re seeing that is a fragility. So what’s happening is children normally what they call antifragile. Nassim Taleb has this term antifragility meaning it’s a system that gets more resilient and stronger the more you stress it within tolerance. So as long as you don’t break it with an adverse childhood experience, in other words, there’s a molestation or some terrible sexual abuse or physical violence that will break that child resilience, if you stress it within the tolerance of that, like let it go out, let it, suddenly I’m already objectifying, this is such a doctor thing. Let this organism proceed to the tree where it shall fall and injure itself, but not severely, just enough to stress the system that it realizes it can take risk, here’s the limits of risk, here is my own resilience and strength, and they get stronger. What we do now is we force our kids to watch TED talks on resilience so that they’ll have the tools and then tell them you know what, the only way you’re gonna succeed is by kicking ass in college and doing really, really well, and crushing the MCATs and the SATs and all of this, and so it’s a mix of overparenting turning them fragile with over expectations burning them out and costing them sleep. And it’s this vicious stew that now I think is leading to what we’re seeing as early chronic diseases. You’re seeing hypertension in teenagers now.

– It’s shocking.

– It’s crazy.

– Yeah, yeah.

– And so you have techniques that you talk about with parents and that you do yourself, like sitting at the table, I heard you sit at the dinner table and you talk about your day in a vulnerable way, like who does that?

– Yeah, seriously.

– Are you trying to show weakness? Never show weakness, okay? I’m telling you babu, don’t do it.

– I know, seriously. I know, and you know, just for the audience who are wondering how did we go from talking about insulin to all the sudden parenting, right? And why did I get involved with this? Was my book not selling, or what’s happening here?

– [Zubin] The South Asian Diet Solution, which is a fantastic book, we’ll put a link in the thing.

– But really, I mean the reason for this is because you and I, we’re all that root cause, so I have so many educated people that come to see me in my clinic. They’ve read my book, they’ve done, they’ve looked at all my resources inside out, they know everything about insulin, but they’re still not making a change. So then I’m like okay why, with all this content and knowledge, are we still not able to make changes to reverse your chronic health conditions? So then you start thinking that, okay, there is something about the way they behave on a minute to minute basis, you know? They have an opportunity to eat this food, to walk, do this, but they refuse to do it. So then we got to step back and think okay, how we were raised? Was health not a priority in your family growing up? Like, were your parents physically active? Did you play some sports? Like, what’s leading to that? Because if we want to really kill this at the root and not deal with these sorts of issues at such a rampant rate, we’ve got to look at the emotions and it really, in a lot of my talks, I tell people I think insulin resistance is an emotional disorder, you know–

– Oh snap. You know it’s all in my head, bro? ‘Cause you can’t tell me that, ’cause I need a medical condition that I can treat with a pill ’cause you start telling me that it’s in my head, I’m gonna react and project and get very angry, right? Do you get that response?

– I get that sometimes. Yeah, but know, again, just like I do with my kids, when individuals come to see me the clinic, they see an Indian male, so they assumed a lot of things about me–

– [Zubin] A very handsome Indian.

– Thank you very much, I appreciate that.

– You know what, you look great. I’m not just blowing smoke.

– Yeah, props to the makeup people in the back. But yeah, basically, they look at me, and they already expected that okay, here’s an authoritative Indian physician male figure, so this is where, and this has evolved for me, because maybe I was at 10 to 12 years ago, but I will lay it on the line. I’ll tell them stuff like, you know what, I struggled when this happened. Like when they tell me you know, my in-laws are visiting for six months, I was like I hear you, man, I know how tough it can be when you’ve got family in the house, and all this happens–

– [Zubin] I’m getting chest pain just hearing that.

– Right, you know, but little things like that, if we can open up as strong Indian males and say that, you know, we feel this too. Because you know, a lot of people have an impression by looking at sort of the work that I’ve done that I’m leading the perfect life, like Dr. Ron doesn’t have chronic stress, obviously, he’s meditating every day, he’s eating all the right foods. Hell now, every day every day, I’m trying to figure out ways that I can make my bedtime correct or where am I going to squeeze that workout in. So it takes effort, and I think as health leaders, if we say that it’s an easy process that everybody should be able to do, we’re doing a disservice, right? So if we can show that vulnerability and how we sort of got around that, and teach those tools in a methodical way, that are actually achievable and not give them a list of go to be early, meditate, eat healthy, and exercise, which I used to do back in the days and then patients just hit mute, right, by the time you’ve hit the second or third thing, I think that’s really key. I don’t know if I went off topic on what they question was–

– No, that was exactly what we were talking about, and I think a piece of that is this emotional piece. That’s what really resonated with me when I heard you on Attia, and you guys only really glanced the surface because you talked about the deep metabolic stuff. The deep psychosocial component of this is an ingrained unconscious level of stress and it resonated with me, and I think you said something about talking about ourselves a little bit, right? And you had insulin resistance, like this was something that you suffered, that you had all these problems, you were gaining weight, eating what you thought was the right diet. You found the way, but you’re still working on it. I’m in the same boat with you. And we have slightly different genetics because I’m a Zoroastrian, we’re technically Persian, but the family’s been in India forever. So if you do the 23andMe, I’m 10% South Asian, 90% Middle Eastern by genetics, but I behave very similar to an insulin-resistant South Asian, and so, but I have no inflammation, which is interesting, so at least there’s that, and my family does tend to do pretty well from a coronary disease standpoint, not so well from a stroke standpoint, but I’m digressing, the point being when I was young, the expectations of the parents were so fierce, right, but it was unspoken, it wasn’t even, because they were so busy, they were just like you, it’s just understood you’re going to achieve. I went through all of medical school, most of college having to wear like, get like the industrial strength aluminum deodorant because otherwise, my pants would be soaked, it would be like this, like a full circle, and I didn’t feel stressed, really, but if I ever took my pulse, I had a PVC like every fourth beat, my resting heart rate was probably 80, 90, and so all this physical manifestation of stress that on the surface I denied, I’m like this is easy, I sit in the back of the class, I don’t do anything, you know, I stay the night before, P equals MD, right? Like you right pass, you’re good. But deep down, this was taking a severe toll on, I think on my health and it kind of comes to your heads in your late 20s, 30s, when you start finding signs of insulin resistance, hypertension, these other things, you’re like what the heck? And it took a total revamp in understanding, it took up talking to compassionate people, including Peter Attia, who is one of them, and that people just kind of understood no, this is actually, a lot of this is driven by the cortisol and other things that happen from stress, it’s not a mind-body connection I don’t think, Ron, anymore I think it’s mind-body, it’s like one continuum. So how is it, because it’s hard to addresses with patients when they’re so resistant to the mind component of it.

– So this is where some, so you’re right there are some individuals that have a little bit of a connection to the mind part, and that’s an easy sell because then we can talk about what things we can do, but I’ve got other that basically, they’ll refuse to meditate, it’s too woo-woo for them like you talked about in the beginning. And this is where, you brought up a very interesting point that you could feel a PVC on your fourth heart beat, right? So what are some physiological manifestations that we can maybe use technology to track? And this is where I do often, I teach people, you know, a lot of my individuals, even though they’re wearing an Apple Watch or a Fitbit, they don’t know what their average resting pulse is. I’m like do you know what your heart rate is when you commute to work or when you’re sitting in a meeting? And they have no clue, right? They’re only check their heart rate when they’re on their elliptical machine, when they’re exercising if they even do that, but what is your average heart rate throughout the day when you’re doing these stressful situations, and just give me feedback on that. And that to me was really powerful when I started doing that a few years ago ’cause I thought that during this meeting things are okay or during this drive, and I found that often, my heart rate, although heart rate can be variable for other reasons, my average heart rate was much higher than I thought. I think I was internalizing a lot of work stress or maybe thinking about the family, and then as I sort of incorporated breathing techniques throughout the course of the day, during meetings, you know, during times where people can’t even tell that I’m doing this, I was able to bring my average work and commute heart rate down. And I could see that objectively on my Apple watch. So I’m trying to use a lot of left-brained tactics to introduce people to how breathing slower, how mindfulness can help them, and once they feel better and they’re like wow, I don’t forget stuff as much, I can perform better, my sleep’s better, now that’s sort of the gateway drug, now I can get them to deal with you want to go even further, maybe doing some seated sessions, et cetera, might work. So that’s one way I kind of introduce it to skeptics and then, of course, I have so many people, we talked about, you said earlier that if their bedtimes are off, and they’re stressing it night time, their glucoses go haywire in the morning, when they start doing that and they see their glucose numbers improve, even their morning blood pressures improve, now they’ve bought into it. So if we can attach some sort of objective number to that behavior change, can’t always find one, usually you can, then all the sudden you can pull them along into the right side.

– Yeah, so you can motivate them emotionally with the kind of stories of the benefit, but then you really need to direct their little rider and say you know what, here’s ways you can measure and you’ll see in real time. And Peter talks about this using continuous glucose monitoring and how, you know, if he’s stressed or if he’s like not sleeping, he sees an immediate effect on his glucose, it bumps up. And you know, over time, that’s gonna potentially be damaging, although we don’t really know, right? It’s still early, but at least it’s a number that correlates to a physiologic response to stress. Blood pressure is another interesting, you know, I myself find that, I had a continuous blood pressure monitor, a finger-based one, that we were doing a show for a company called Edwards Lifesciences, and during the show, it was a professor from UC Davis was teaching me about intraop continuous blood pressure monitoring and predictive algorithms that can actually use AI to predict right before you’re gonna become hypotensive, so the anesthesiologist could respond because there’s some correlation data that if you dip your blood pressure too low during the OR, you have bad outcomes. And now again, we don’t know that’s causative. So he was teaching me about this, I have the monitor on. The sales rep who was monitoring the device, I could see him in the corner like kind of panicking, and I found out, you know, afterwards that you know my systolic blood pressure would get to 220, my diastolic will get to 180.

– Seriously?

– yeah, seriously, during a live show. This was a live show. Now, I felt, in retrospect, I remember feeling like, and why am I telling this story? It’s not about me, I’m telling story that people don’t realize–

– That’s exactly right.

– That they’re harming themselves. So, during the show I remember feeling some heaviness in my chest, and a kind of a general tension that often I would associate with being live and the energy of being live, and how awesome it is to go live especially in a strange place with strange people to hundreds if not thousands of people, and I always thought this is just second nature for me, but my unconscious mind is like you are in fight or flight gonna die mode. There is a tiger ready to bite your head off. And it manifests that way. Now, if I do that consistently, I’m gonna have lacunar infarct, I’m gonna get early dementia or stroke and it helped me, that measurement helped me understand what was going on, so now before I go live, I already kind of get into a mindset where I’m like this is not worth dying over.

– Really important point. So what you’re describing, and same thing with me, like my resting heart rate is about 50, and when I do talks, I’ve actually monitored it, it doubles, it can go up to 100 or 110, okay? And that doesn’t mean I should quit sort of doing, you know, speaking gigs and things like that because it’s kind of like exercise, right? If we exercise intensely, blood pressure, heart rate are going to go up, but we’re looking for the long term gains of that, right? It’s gonna have positive, beneficial vascular effects, all the great things that happened with exercise, but when I started seeing this impact in my body, what I realized is I needed to make schedule shift because normally I’d go out to a company, I’d give a talk, I’d race back in the clinic to see patients, and seeing patients raises my heart rate as called too, so I basically had to make sure that I need to schedule some space. Like if I’m done giving a talk at a high-tech company, I’m not gonna immediately go back and see the next slot in my patient schedule, I’m gonna walk around the corporate campus, come back, I’m gonna actually come back and do some slow breathing, bring my heart rate back to back down because really, giving talks and doing the work that you do, it’s energizing, right? I think it has health benefits because we feel like we’re doing good.

– Connecting.

– Yeah exactly, we’re connecting. but if immediately after that, you’re doing adrenalin-driving activities after that, then it is gonna take it toll. So I think I’ll just have to look at our day and say what are the things that energizes us? But are we creating spaces for us to calm that nervous system and that vascular system down? That’s really key.

– You know, and if you get a headache after your talk, and I used to do this, you know that you’re probably hitting a high blood pressure and you made an important distinction which is when we exercise, yeah, our blood pressure and pulse can go up, and these things can happen, but we’re coupling it with an opening of the vasculature in the muscle beds, creating a decreased peripheral resistance in that way, and that’s very beneficial long term. If you hit somebody with high blood pressure and high pulse rate, and you’re just sitting there, that is very, very, very long-term bad. And again it doesn’t mean you stop the things you love to do, it means you do things like you said. So it’s funny, I remember still like TEDMED 2013, the Washington, Kennedy Center, I’m the last talk of the day, and everyone’s expecting me to like you know, oh this funny doctor is gonna come, and he’s a rap doctor and he’s gonna make us laugh and so I am stressed. Like I had to introduce Richard Simmons which was weird with the Surgeon General, the whole thing was kooky, and Richard is, you know, a little bipolarish, and so I was super stressed, so before I went on stage, I just did one thing, and I said you know what, I’m in the present moment, it’s a gift to be with these people and get to connect. What a wonderful job, I’m at the Kennedy Center, took a deep breath and you see me on stage do it, I just go and then I start to talk. And it reframed everything. And afterwards, I didn’t have a headache, I felt great, and all these things. You know what amazed me, you said you go from a talk, and you just go and see patients after that. I couldn’t imagine that, I’m so spent. I’m just done, I’m like I can’t talk to anybody, and yet I do, but it’s really–

– I mean, my day I tell people it’s kind of like interval training, right? So you’ve got these events where you’re spiked, and before it was just spiked the whole time, you know, but now that I’ve incorporated, and literally sometimes, honestly, I mean thank God for little power naps. Sometimes I will be in the car, it’s quiet, I’ve got calming music on, I might have a calming app on, and then for 10 to 12 mins I just shut down, and then I’m recharged again. But you know, when I take a lot of my patients’ histories, you know, moms that are busy between work and picking up the kids, there’s no down time at all, it’s a continuous, and they wonder why are they developing autoimmune conditions. The body is literally telling them that you’re not resting at all, so we need to be in high alert mode.

– Oh man, let’s double down on that, so, a lot of our audience are nurses, they’re the nurturer phenotype, they give up everything to take care of others, a lot of them have been traumatized when they were younger, and so they have this thing where I can help others and thereby heal myself, and I hear from them the stories of autoimmune disease rampant, hypertension, young strokes, PCOS, young cancers, all these kind of things. Is this the same phenomenon that we’re seeing?

– It’s similar, yeah.

– What would you tell nurses? They have busy shifts, they’re expected to do more and more with less and less, give us a magic bullet, Ron Sinha.

– Wish there was a magic bullet, but what I will tell you is it comes back to my principal of how do we incorporate healthy practices during work hours? So with stress, for example, one thing that’s really helped many of my patients and help me is really just a regulation of breathing. So one simple tip I want to give you is a lot of us that are sort of mouth breathing throughout the day, if we simply during quiet moments close your mouth and we breathe more through our nose, so nasal breathing, that will automatically help regulate your nervous system. If we go beyond that and do a practice called nasal humming, believe it or not, so if you like music and you basically hum a tune, and you don’t like that that actually has additional benefits. So again, for you left brain skeptics out there, they did this study were these functional MRI imaging and they looked at brain scans of people sort of making different sounds to see what impact it had on the brain. And so they had people literally do the humming sound, the and what they found is as they hummed, the limbic system, the midbrain, all that overactivity actually shut down. It got dampened by that specific sound, versus if they were saying or some other consonant sounds. So I’ve actually taught some of my patients to nasal hum. I’m like you’re in the car, just hum, and do that throughout the day. Nasal breathe, don’t breathe with your mouth, and although we’re not removing external stressors of having a terrible boss or financial situations, they find that they can navigate things and just be much more calm throughout the day. And if they’re tracking their heart rate, they find that gets better. And you know, often even background science, I’m actually literally sometimes charting in an exam room and I’m nasal breathing or I’m nasal humming while I’m doing it, and by the time I hit my second half of the day seeing patients, I’m in a totally different zone.

– Dude, okay, I’m sure it activates a parasympathetic nervous system and that sort of, this kind of of calming thing, but that’s the most annoying thing I’ve ever heard, Ron. Could you imagine like Sharon’s at the nurses station and she like ♪ I said yo what a concept ♪ No, but actually, all joking aside, that’s a really cool, interesting tip that I hadn’t heard.

– And it’s something, if you’re too embarrassed to do it obviously in an exam room, I tell people my car is often my stress release chamber.

– Ah, there you go.

– So the commute is key. If you love music, play music and sing as loud as you can. Even if you are have a terrible voice, sing as loud as you can–

– Guilty.

– Oh, I’m sure you are. Yeah, and you’re activating your diaphragm, right? So at least sing. I have like old 80s tracks I listen to, I’ll sing my butt off on these so I can just activate the diaphragm.

– [Zubin] What’s your track of choice?

– Aw, man.

– Come on, man, bring it. Give me some Def Leppard.

– Oh, Def Leppard is definitely one of them.

– Do you take sugar? One lump or two.

– Right.

– So just singing at the top of your lungs, that diaphragmatic parasympathetic activation, vagul nerve.

– Absolutely, so what I love about your line of work is that’s part of it, is music, the second part is laughter, right? So listening to podcasts, whatever you can in the car, and laughing even louder than is necessary to activate your diaphragm because all of us are still contracted, right? We’re in front of a computer, we’re seeing patients, our diaphragm is contracted, we’re breathing up here in our chest, and when I get in the car and I’ve had a stressful day, and I’ve got to go and be a parent at home, often I am doing release techniques in the car, I get in the garage, I might do some nasal breathing or before you walk in as a busy mom/nurse, maybe you need to take a walk and just do some slow breathing before just going from a high-stress job right into that environment. So think about some of the things that you can do there.

– That’s really great advice, you know? And the other the other advice I’ve heard you give which I thought is great ’cause I tried this myself is, look, you may not have time to 30 minutes of mindfulness meditation that the wellness people at the office are telling you, and you know they’re trying to sell you this thing and you’re like wah, come on, they’re just trying to get more RVUs out of me, right?

– Yep.

– Right, but what you can do is take some of those techniques and spread them out throughout the day. Like you said, it takes just a minute to do some deep breathing as you’re in a meeting, about to start a meeting, you’re about to take report, you’re about to give sign out, you’re about to pick up the phone and bills about to sign out a train wreck service to you, and your likes okay ♪ The world is ♪ Okay, maybe not that. Smash Mouth has been clinically proven to raise blood pressure in nine out of nine. So actually, we kind of tipped on this thing, healthcare professionals are not a healthy bunch when it comes to stress. And we’re all having this really difficult time where, and I actually did this rant on moral injury and how it’s not burnout, it’s moral injury, and yeah, that’s true, but you cannot externalize it too much. So by saying the system’s broken and it’s causing us this moral injury of having to work in a system where we can’t help patients, we can’t take care of our families, we have too many bosses, we’re inclined to have to please the corporate masters, the malpractice people, the lawyers, the patients, our family, ourselves, Indian dad who’s got all these expectations, and it creates this conflict that leads to depersonalization, low feelings of achievement, depression, cynicism, these kind of things that we call burnout, I did a rant about this and it got quite a lot of play. The one thing I want to mention and follow-up is but you are then, you’re removing the locus of control from yourself and I think that’s harmful. You have to make sure, yeah, there are these systemic problems, until we fix them, the problems will persist, but there’s too much work, there’s too much self-imposed stress, and we feel like the way we treat that problem is by working harder. And so there’s a lot of internal dysfunction in our ability to be resiliently responding to this dysfunction that harms us, do you agree or how do you think about this?

– I think you’re absolutely right, and as much as we’re putting the healthcare environment, you know, talk about Silicon Valley again too–

– Yeah, tell me more about this, ’cause this place is miserable.

– [Ron] No, I know, it’s tough–

– Actually, let me interrupt you for a second,

– No, please, go ahead.

– Because I have been in Vegas for seven years, I was happy, I was content, I found a passion, and a purpose and a team and connection, but at the same time, my friends and my extended family, and my professional network are back here in the Bay. And we kept this place, and we said well, let’s go back now because we want to reconnect in this path. The minute I got back here, a misery descended on me. There’s something about this place that causes this expectation of striving and accomplishment and why am I not making more videos and why are we not out there doing this and I’m yelling at my team and I’m losing my temper and I’m worried why my daughter isn’t in advanced math when she crushes it everywhere else, and I’m losing my freaking mind, Ron Sinha. Now, is it this place? What are you noticing in the Silicon Valley or is it a mindset that can be anywhere?

– It’s a mindset that can be anywhere but it is true then Silicon Valley the individuals to come here, come here to do great things, you know? Whether they’ve come from any parts of the world, they’ve read the Fortune magazine covers, they’ve seen that if I come here, I can start a company just like this person that came from the same village. So you already come in here with sky-high expectations for yourself and for your kids as well too. And here’s where the parental stress comes in because we know the majority of people who move here or not gonna become Elon Musk, right? So it’s just not gonna happen–

– You shut up, Ron Sinha.

– [Ron] Sorry.

– I’m gonna to Mars, and I’m gonna do it in an underground tunnel. I’m gonna build an underground tunnel to Mars, okay? But you’re right, we’re not.

– We’re not. And then when we don’t achieve that, so let’s say you and I worked at a company, okay? We both work at a company, we’re great friends, you on the side, you’ve got a side hustle, okay? You’re doing some sort of startup app, and I’m like, yeah, whatever–

– It’s essential oils, bro.

– Yeah, essential oils. There we go, right? And so we’re doing this work, and then all of a sudden, you hit it big. And as much as we’re close friends, you hit it big, I’ve got some envy going on, right? So how did Zubin make it so well, and I’m still working at the same company, I’m still stuck here? I’m gonna hear this narrative over and over, but guess what, we also have kids that play together, and they love each other, they’re great friends from early on, and all of a sudden, your kids doing like let’s say an entrepreneur bootcamp on the summer, they’re playing this sport. Then I subconsciously think, you know what, I want my kid to sort of do this or up it because you beat me in the game, but maybe my kid can be you in the game because the way I can beat you is by telling you guess what, my kid goes to Stanford and yours doesn’t. Or my kid goes here, right? So we need to acknowledge the fact that a lot of us are living on the coattails of what our kids do, and that’s providing so much unconscious stress, you know? So one thing is number one, when we come here with high expectations, acknowledge the fact that we’re not always going to meet those expectations. You know, I think the biggest lifestyle change for me has been to, on a daily basis, lower my expectations around everything that I do. And that might sound like I’m not motivated, but literally, that means that, you know, if I’m giving a corporate talk, in the early days, I’m like why aren’t there 1000 people here? I put my time aside, but now I’m like even if one person shows up, what an opportunity for me to connect with one human being and make a change there. I go to restaurant, I’m like you know what, thank God I’m in a restaurant and people actually serving me food, they’re waiting on me for God’s sake. If the steak doesn’t taste good, who gives a crap, right? So everything, and it was a practice for me, but once I started doing that, and I remind my engineers and people to come in, there is someone like you in India right now that would kill to work at a company where you’ve got, you know, on-site hair cutting, massage, everything, and you’re sitting–

– [Zubin] Shit, I’d kill to work at that company.

– Exactly, and that’s a key thing. So when I see doctors, ’cause I have a lot of doctors in my practice, the ones that are burned out they tell me I wish I worked at a high-tech company. You know, I wish I worked there, I’d be so much happier, I’d have everything served, we don’t even have a gym in our, I mean like, they have gyms, they have everything. In the meantime, I’m looking at the health claims of you know, all these corporate companies at a mass scale, mental health disorders are at the top of the list, the number one prescription being prescribed are antidepressants. And sometimes, I’ll see these high-tech workers and they’re like God, you know what, I sit in front of a computer all day, I wish I wen tot med school, you know, so it’s like an if/then, right? It’s like if I done this, maybe if I stayed back in India, I’d be happier ’cause I’d be with family. Maybe if I moved out of India and went to the West, I’d be happier maybe. Maybe if I became an engineer, I’d be, we keep playing these scenarios in our head, if I move to Vegas, if I move back here, but there is no 100% happiness solution, right? So I think if we know that all sides are suffering, and to me, that’s kind of the connection point is everyone’s suffering, people at the top of the food chain in corporate America, people who are doctors, nurses, but how do we sort of share our suffering and try to heal each other? I think that’s the key thing.

– Oh, man, that’s a ride you took me on, man. It feels so true, and the thing is having, again, having this jarring return ’cause you before I left, I was this way. I was a striver and it’s a hedonic treadmill, if I could just do this, and you know, and then you hear dad’s voice in your head. If only, if only, he always says that, if only I had specialized, if only, and then that ingrains in you, and you’re like well, everything has always gotta be a little bit better. Oh, we did a remodel on the house, but you know there’s a nick over there now, so. Whereas, you know, when I was in Vegas actually, it was interesting because the environment was different, it was a blank deserts slate, so you bring to it what you want to bring to it.

– And I got woke early on there with a friend who just was like this what it’s really about, it’s about the present moment, it’s about here’s some books you can read, here’s some stuff you can learn, and I’m like what? There’s a present moment? You mean there isn’t just worrying about the future and striving towards it and regretting the past? And it’s blissful, and I get that back here when I meditate, but then I lose it during the day because there’s something about, you know what it is? It’s the collective culture of it, and you can get sucked into it. And I think people need to realize that, what you just said, that everybody’s suffering. The person you think is the happiest that’s rich and doing all these things is on antidepressants, is stressed out, has early onset coronary disease.

– And that really was an awakening moment for me because of the work I do, I take care of a lot of execs and entrepreneurs, and these are people that other people and communities would think I want my kid to be like that person, I take care of the families, so I know the second or third wife as well too. I know like all this stuff that’s happening. And to me I’m like, you know, if you had a choice right now and I asked you for your kids, would you rather have them be, I’m not saying there’s a black and white, but just a thought exercise, would you rather as a parent have them be a super successful entrepreneur on the covers of magazines that you can brag to your friends about, but their health is a mess, their marriage is a mess, they’re emotionally a mess, versus somebody that doesn’t have a Fortune magazine front cover job, maybe not as respectable of a job, but they’re living a fulfilled life. Great marriage, no health issues, which one would you choose, right? And that’s the thing, because we’re pushing somebody in the direction of achieving that reputation, status profession, and they’re sacrificing their health, I end up seeing the parents of those entrepreneurs ’cause I have to take care of two or three generations, and they come back and tell me why is he still working so hard? He had a heart attack, why is he not slowing down? And that was really a compelling point is I saw a female patient see me who had a heart attack at age 45, and she was in there with her parents, and basically, the parents were saying you know, I can’t slow you down, you know, what what’s going on, you had this heart attack, what’s happening? And she just said something that just stunned me, and that was a revelation to me, she was like you guys never taught me to slow down when I was young, you told me to be the best, we never talked about resting and things, so that’s the way I am. And what I heard that, I’m like my God, I’m already, you know, the way I’m parenting my kids, the way I’m raising myself, if I’m creating that sort of a wheel where they don’t know how to acknowledge and slow down, then you know, what am I done as a parent, right? Other than create a profession for my child that I can brag to my friends about. Is that really what the purpose is?

– It’s absolutely it, and you know, I’m doing my best to stay focused on a practice and a philosophy that I developed over seven years, but it’s amazing how quickly it can regress, and so you have to be mindful all the time. You know, it’s funny, you told that story about your patient, so I took care of a VIP patient, name, sex, all that’s gonna be withheld. This person is one of the most successful people around, by any stretch of the imagination. When this person’s parents came in the room in the hospital, they were hooked up to a dinamap, pressure had always been normal, pressure was 180, 190, just talking, looked like a calm interaction, but the unconscious stress, and you said something on Attia’s podcast, one of your talks is called Your Children as a Start-up.

– [Ron] Yeah, Is Your Child a Start-up?

– Is Your Child a Start-up?

– Right.

– Explain that, ’cause it resonated with me.

– Yeah, I mean, I think we do treat a lot of our kids like start-up companies where we back them with all types of finances, resources, we set sky high expectations, this is a child that, you know, I work at this company, but my child someday will hopefully run a company like this and we have so many expectations on that kid. To me, it’s no different than investing in a start-up company. But we sometimes forget that you know what, this is a 10 year old kid. This 10 year old kid doesn’t have to give a TED Talk when they’re 14, they don’t have to go to entrepreneur camp, they have to do this, you know, they just have to be a random kid. I like how Peter talked about the fact, it’s true, what did we do with kids and teens? We were just messing around all the time. And although that might seem technically like a waste of time, it allowed or brain rest, it allowed our body to grow properly, so then later, we can kill it, right? So you know, at least you’re conserving energy, but right now, we’re burning out kids by treating them and expecting that they’re gonna operate like adults. Now the expectation really is when you apply to colleges around here, okay, did you start a non-for-profit? Did you start your own app or did you already launch a company? Literally, in Palo Alto and other areas, that’s the expectation is my kid should have already had a start-up. You know, some of these kids are already selling their first companies with a lot of parental assistance, but you know, it’s crazy. So you know, and just to, even though I’m saying all this, every day it’s a struggle for me too ’cause I’ve got to reset my thermostat, but the key thing that you mentioned is even if you can voice that in your head and say there is my unconscious dad telling me this again or sometimes like there I go to type A Ron again. If you can externalize that, and watch that just as an observer, that still helps the situation rather than just go through this rat race completely blinded, right? And I talk to that about my kids ’cause they have some friends around them that are just such type A achievers–

– Gunners.

– They’re gunners, right? That’s the word we use. And I’m like you know what, I don’t feel, I mean this is what’s happening basically, you know, and we sort of characterize it as like what do you think their cognitive behavioral pattern is? We sort of do a little of psychobabble, but I like to have them step back and sort of feel this is what’s happening, and they sort of know the types of patients I have to take care of, and I’d never wish any harm upon anyone, but I’m like, if that individual doesn’t learn to slow down they’re on a race to basically poor health later on, so I can pausing and stepping back is really key to be able to watch that as an outsider.

– Yeah, I think you nailed it. I mean last night, I had an experience, so as putting my eight year-old to bed, and she’s a gunner, she’s a little gunner. She’s like really good at stuff and kind of, and I don’t push her because she automatically pushes herself, and she was telling me, and she was laying in bed, we read like Diary of a Wimpy Kid and she goes Daddy, should I do what Mommy does when I grow up? Should I read X-rays and things like that? ‘Cause Mom’s radiologist, and I’m like what why are you asking me that? She’s like I need to know what I’m gonna do, I need to be able to make money, or I’ll be out on the street, like I need to do that. I’m like you’re eight. Like first of all, awesome thinking, kid. I like the way you’re thinking ’cause you could be on the street at any time, I like to instill this sort of general that nothing is a taken, that’s an Indian thing too, at any minute, you’re on the street. But at the same time, I told her you’re a child. I want you to think about being a kid. I want you to go out and play with your neighbor next door and have fun in this beautiful part of the world we live in, I want you to eat fun food and hang out with Daddy, and not worry about the stuff ’cause there’ll be plenty of time. I told her there’s 10 years before you need to even think about what you’re gonna do with your life, all right? But if I didn’t have the little bit of wokeness that I have where I was like, ’cause an earlier me, would have said you know, I’m glad you think about this. Okay, here are the different options.

– [Ron] You would be ready to monetize on a moment, right?

– Immediately.

– Yeah, totally.

– I’m like you know what, I know a guy who can code. Here’s what we’re gonna do, we’re gonna create an app for kids, it’s called Doc Doc Goose, This has been my idea for an app. It’s a dating app for medical professionals, Doc Doc Goose. It’s only doctors on there ’cause we know doctors should only date doctors.

– [Ron] Oh God, help us.

– And yes, so that being said, I think it’s important to have that. You know, one thing you also talked about with Peter a little bit that I wanted to follow up on was the sports thing, in Indian population, and in immigrant populations. A lot of times, that population didn’t grow up with organized sports beyond a little soccer out in the thing. And my Dad recently told me this story, so he, my dad is now, he’s turning 80 on Monday, and I’m going to Fresno, Clovis, where we’re from actually, still live in you know, Damania Manor.

– My mom’s in Bakersfield and I used to go to Fresno all right the time, yeah, for soccer–

– Your mom’s in Bakersfield?

– Yep.

– What the, dude, who is your high school?

– West High.

– West High? You know Clovis West?

– Oh, look at that. So we would probably–

– Yeah.

– Now, I never did sports, so what would happen, my parents never taught me sports, my dad never taught me to catch, I did do a little soccer which was interesting and I ran, and I was always active, so I did skateboarding and that kind of thing, but never organized sports, always ostracized in the community that was all about sports. So a bit of an outsider, chubby, all the other stuff. So I find it for my dad ’cause now that he’s 80, he’s telling me these stories, like you know, I never told you how I grew up. And he grew up in a British boarding school outside of Mumbai, and that his parents sent him to, ’cause his parents were super poor, but because they were Parsis, Zoroastrians, the British loved Zoroastrians for some reason. So they took them into this boarding school and would give them three meals a day, and it was basically like a little rice and if they were lucky, they’d get half an egg or something like that. And everybody played soccer, but nobody did any other sports, and they had to sneak into the theater to watch a movie, and a movie was the biggest thing in the world. Now I look at him, he’s got this big 100 inch TV, and he’s obsessed about movies, he hates sports and all this other stuff. And I’m like oh, this is like ontogeny recapitulating phylogeny. Like the generations to on and on. And a lot of these Indian kids come here without, the parents didn’t have organized sports, but the parents now see sports as a competitive tool.

– Oh, yeah.

– And so what have you seen in these kids and sports? It’s interesting.

– Yeah, you’re right. it’s a competitive tool, and it’s a way that people really get respect, social respect in communities. I mean even here in Silicon Valley which is so academically driven, I mean people love the attention they’re kids get when they’ve performed in sports. And so a lot of the immigrant populations find out, because you have talked to a lot of parents and often they feel socially isolated when they come here, right? They have a tough time mixing maybe with non-Asians, but they find it wow, if we show up at basketball games, soccer matches, this is a way to sort of assimilate and integrate. And at the same time, like you said, develop competitive skills, leadership skills as well too, that we didn’t so, but I do want to say that as much as we focus on sort of South Asian and Asian, people ask me is this just a tiger parent thing? And I’d day in high-performing areas like here Silicon Valley, New York City, Washington DC, it doesn’t know any race, right? I mean all ethnic, everyone’s a gunner, you know? And some people are super gunners with sports, and as much as you can justify in your head that well, that’s good at least ’cause they’re exercising, I actually would argue no. I mean yes, the exercise component is maybe to a certain point, but if you’re going to so many practices and events where you’re basically eating junk food on the way there ’cause mom and dad don’t have the time to get a healthy meal, again you’re compromising homework times, you have to come back and go to bed late, a lot of these kids aren’t growing. You know this is just an anecdotal finding, but I’ve talked to a lot of PE teachers and coaches and they find that a lot of individuals are becoming very vertically challenged despite having taller parents. And my theory on that, and I see this in all ethnic groups is because you’ve got a specific bucket of nutrients that are diverted towards the growth, that are dedicated to growth, and if on a daily basis you are exercising so much that all those nutrients are going towards energy production and you’re not allowing proper rest and sleep, you’re probably gonna take a hit in inches along with other areas of your health too. So again, coming back to the main point, I think everyone’s a gunner in some way, but in certain parts of the country and world, that’s on steroids basically, it just depends.

– So this idea that you know, so these kids are really good at sports, they’re exercising all the time because their coach is making them train and stuff, they may be losing inches of height, potentially, who knows, right, like you said, but what’s interesting is when the sport ends, they hated it, unconsciously, ’cause it was forced on them, and they don’t exercise it all. They don’t know how to exercise for fitness. So they’re not out there gently jogging or on a StairMaster or doing resistance training in a way that’s actually sustainable without injury that keeps the weight off and improves insulin resistance, creates muscle mass that is more parking lots for that glucose, better insulin resistance, et cetera, is that wat you’re saying too?

– Yeah, I mean, again, coming back to a lot of my entrepreneurs, many of them were burned out athletes that played soccer like crazy, they did crew, whatever they did, and now they really don’t exercise for pleasure, and it’s the same with music too. Some of them are actually have, you know, I didn’t realize this when I get started playing piano that there’s a specific track that you can go on where you can put it on your college credentials like literally, you take a certification test, and we had no idea, and their first piano teacher told us about that, and we’re like this is weird, and then they were not enjoying the music at all. It was just like another school subject. So we scrapped the teacher and we got another teacher that plays movie theme music, and they’re already obsessed with Star Wars, I mean you know that, where can you go wrong with that? They love that, and then their latest teacher, we just shifted for a different reason, is introducing anime and music that they love, and now literally, we can’t pull them away from the keyboard sometimes. And to me, that’s like that’s a blessing to me because you’re developing interests and hobbies that they can use later in their life when life is chaotic, right? I want them to turn on the keyboard and not resent that, so–

– Absolutely, so the can be like ♪ Somebody once told me the world is sure to roll me ♪ ♪ I ain’t the sharpest tool in the shed ♪ It’s funny ’cause my daughter, my eight year old, they both play violin, they’re really good at it, and they enjoy it, I think, because we’ve asked them to quit several times, we’ve asked them to quit ’cause it’s hard on us. And yeah, I’m like this is about us, okay? And they’re like no, we like this, we enjoy this, it gives us joy. I’m like okay, cool. Well, she picked up my guitar, which is way too big for her, and I showed her how to play Jesse’s Girl, you know?

– Oh, fun. ♪ I wish that I had Jesse’s pen ♪

– I’ve never seen you, in any of your videos, do you play guitar at all?

– Occasionally, yeah.

– Okay, I’ll have to look for those, that’s fun.

– But I’m not that good at it, because I suck, but I only played it for fun, I never played it, you know, and so it’s still a joy in my life, like you said. To this day, if I’m like feeling stressed, I can pick up a guitar and just play stuff. And it’s now helped and formed what I do in my life, with the show and everything else. But so she picked up the guitar, and she’s like this is to much fun. I want a guitar that’s my size. And I was like yeah, yeah, yeah, sure, you’re gonna play it. No, she’s like really, please, Daddy, when will you take me to go buy a guitar that’s this size? And I was like are you kidding me? She says no, I will play it every single day, this is so much fun. I’m like I’m gonna go this weekend and get her a little guitar. And then she’s gonna stop playing it or she’s gonna smash it over her sister’s head. But either way, this idea that joy, that you know, this is really what life should be about.

– You’re right, it’s present day joy because you know it’s interesting, so I gave a talk at a particular venue where they had some college counselors there, and this is a type A college academy, and literally what this talk was is you work your butt off right now and do all these things, and you’re gonna defer joy because you’re gonna make it to this school, you’re gonna get here, you’re gonna have unlimited money. So it’s always that deferred gratification. And we heard this from parents too. Work hard right now, and you can become this, and you’ll have millions of dollars, whatever.

– [Zubin] It’s the medical saga.

– Yeah, exactly, it is a medical saga. But it’s like if you don’t create opportunities for joy now for your kids and yourself, you’re gonna, like you said the hedonic treadmill’s gonna keep spinning, and you’re gonna miss all these opportunities, they’re gonna blow right by you.

– Life is gone, you’re on your death bed full of regret. And that’s, I’m not gonna allow it to happen, I’m not gonna let this place destroy me, Ron Sinha .

– [Ron] Right, exactly.

– This place is the dark side. It’s one of the most beautiful places on earth, the food is amazing.

– It’s a mirage sometimes.

– It’s a mirage. And then, you realize the people are stressed, man, and they stress you out. You gotta transcend it and there’s ways to do it. Now, I would be remiss if we didn’t end the podcast, if I ask two other questions. One is what’s the deal with vitamin D and sun? Because that’s something that seems like people’s vitamin D levels are low, particularly in South Asians. How are you thinking about that? Are you repleting vitamin D by supplement or what are you telling people?

– So there’s a lot of murky science behind this. So what I would say is I think there is a camp out there that thinks with vitamin D levels, that the higher you go, the better it is. So they’re going 60, 80 plus nanograms per milliliter, and I think there’s risks to that. But on the other hand, if you’re someone that’s in the teens and really low, I don’t think we’re doing your body any benefits by having you that low. The first step would be, if possible, can we get more sunlight exposure? Now, if you’ve got dark skin and you’re on a day job where you have to wear clothes, you’re not a lifeguard, it may not be adequate to get enough sun to get your vitamin D levels up to normal, but my first message is let’s try to get more sun exposure. This is a sign, a metabolic sign that your body is calling out for more connection to nature. Now on top of that, we probably, you know, vitamin D rich foods can help a little bit, but we probably have to supplement you up to a specific level because if you look at vitamin D studies out there that show there’s no benefit, the vast majority of them did not even measure levels of vitamin D before and after. They’re just looking at outcomes. They’ll put you on whatever, 400 units of vitamin D, which is hardly anything, and then let’s see what happens to fracture risk or outcomes on various chronic health conditions. But if you did a well designed study, and the few that are out there, you often do see improvements in things like blood pressure and glucose metabolism. So I’d say it does have a role in moderation, lifestyle first.

– Lifestyle first. Get out in the sun a little bit, if you’re a Caucasian red head, probably less good to do that.

– Right, exactly.

– Higher cancer risk. And then intermittent fasting. Because this is a path that after going through low carbs, ketosis, that kind of thing, I’ve kind of settled on as a sustainable path for me. I’m just a one meal a day, type of restrictive feeding window. What’s your thought on intermittent fasting, benefits or lack thereof in your population that you treat?

– So you have to customize it, just like anything else. So I know it sounds like a cure all for everyone. For some individuals, it works phenomenally on every front. Typically, those tend to be males, it works very well. For others, because we see so many individuals, particularly females, that are coming into my clinic already nutrient-deficient, they already have a lot of inflammation. If you tell them to eat one meal or two meals a day within a tight window, you’re missing out on opportunities to provide adequate nutrients that their body needs. So I tell people intermittent fasting is sort of, it might be a goal we work towards, but first, we have to nourish your body before we start starving your body, right? So I literally just saw a patient earlier this morning, and she has not responded well to fasting at all. She’s felt terrible, her hair is coming out, she’s gaining more weight, and she was someone originally I told her if we don’t get your nutrient imbalances corrected first, and work on stress and sleep, this is gonna be a stressor to you, and that’s exactly what it was. Now over time, when we build that system back in, then intermittent fasting might be a powerful tool. And when we say fasting, again, people get competitive around fasting here. You know, fasting in Hinduism was a very selfless act, it was a renunciation, it’s something you offer selflessly to some god figure. But here I go to Silicon Valley parties, hey, how many hours did you do? Oh I did three days, or what about five days, or what about seven days, right? It’s like everything is so crazy here. But for some people, just having 12 hours or 13 hours that might be good to do. Or use intermittent fasting PRN. If you went crazy on the weekend, you flooded your system with glucose and muscles, Monday, Tuesday, Wednesday, now we’re gonna be hitting holiday season, you know, that might be a good time to do some corrective intermittent fasting to empty out some of the nutrients, so that’s the way I think about it.

– I think that’s a very rational way to think about it. Yeah, and it’s different for every single person. So, Ron, man, we’ve done a tour de force here. I don’t know, how long have we been going? How long have we been–

– An hour and 30.

– Hour and 30?

– What, get out of here. Seriously?

– What the heck?

– Oh my God.

– Dude, I was in like a time warp.

– Even I’m shocked.

– I know.

– Right.

– Dude, these guys are like in the back here, they’re like

– There we go, and they’re like meditating back there.

– That’s right except for Tom.

– [Ron] And doing their nasal breathing, yeah.

– ‘Cause in Tom’s mind, he’s nasal breathing ♪ Somebody once told me ♪ Okay, so–

– I’m not gonna get that song out of my head, thank you.

– You’re welcome. So listen, the thing about Ron is he’s got this book, South Asian Diet Solution, is that what it’s called?

– It’s Health Solution.

– Health Solution.

– Close enough, that’s okay.

– Yeah, great book, I read it, wonderful, we’ll put in links. He also does seminars, you have a website yet?

– I do, so it can be my name RoneshSinha.com is the easiest way to get there.

– [Zubin] Awesome, r-o-n-e-s-h

– Yep, and s-i-n-h-a

– S-i-n-h-a.com and we’ll put it in the links. This was great, I’m hoping that for supporters, who support the show and subscribe, they can get CE / CME / CEU credits and CC and AMA accredited credits, and you’ll take a post text, the instructions will be in the web post, because we want to edumacate and entertain like Smash Mouth. I figure they are both educational and entertaining. Ron, you’ve taught me a lot, you’re a colleague, you’re awesome, you’re a fellow brother.

– [Ron] I feel the same way about you.

– And it’s really been a joy to have you on the show, I hope people take away a lot from this as much as I took away from it. Come back, will you?

– Oh, absolutely.

– Because we’re gonna outgun each other ’cause we’re here in the Silicon Valley.

– Right, exactly.

– I’m like oh, Ron, how many views did you get on that show? I bet we could beat it. And Z-pack, we love you. Do me a favor, subscribe on YouTube, click the little bell icon to turn notifications on, so you always get a little dingleberry notification. Is that the technical term? And become a supporter, if you aren’t one already because we have the deep dive discussions. I got a lot of the questions that I’m asking Ron here from our supporter tribe. You can have a voice and we can change healthcare together. What do you think, Ron, are we out?

– We out.

– My brother.

– All right, thank you, my friend.

– What a pleasure, God Almighty, lovely, lovely.