Waiting Speaker 1:
Coming up on this episode of The Doctor’s Farmacy…
Dr. Ronesh Sinha
I tell people, you treat COVID-19 kind of like a sporting event. It’s like you’re training for a 5K or a 10K. How do we get you less breathless through physical activity? How do we elevate your VO2 max? How do we get an inch or two off the waistline? These are all goals that I had even before COVID-19, but how do we accelerate those goals? And now that I’m giving talks to schools, I’m really trying to push, how do we really emphasize physical fitness more in the midst of the pandemic?
Dr. Mark Hyman:
Welcome to Doctor’s Farmacy. I’m Dr. Mark Hyman. That’s Farmacy with an F, a place for conversations that matter. And if you are concerned at all about the obesity and diabetes pandemic… I think it’s a worse pandemic, in fact, than COVID… You should listen up, because we’re going to talk with an extraordinary physician who studied this condition in a subset of the population, Asian Indians and South Asians, which are far more likely to get diabetes and prediabetes at normal weights. We’re going to talk about why.
Dr. Mark Hyman:
We’re also going to talk about cholesterol, which is confusing. There are people who go, statins don’t work. There are people who say everybody should be taking statins, and put them in the drinking water. And there’s a whole range in between.
Dr. Mark Hyman:
So, we’re going to get into all that, and our guest today is Dr. Ronesh Sinha, who is the author of the South Asian Health Problem. That’s an understatement. He is an internal medicine physician, he runs a lifestyle clinic in Silicon Valley, focused on reversing insulin resistance in ethnically diverse patients. He’s also an expert in corporate wellness, and serves as the chief medical officer for Silicon Valley Employer Forum, where he serves as a global advisor to shape health benefits for over 55, that’s a lot, Silicon Valley companies.
Dr. Mark Hyman:
His groundbreaking work is in corporate wellness, and in raising awareness about insulin resistance, my favorite topic, which I’ve written a bazillion books about, in the Asian populations specifically. He’s received global attention with front-cover stories in Fortune magazine, the LA Times. He’s got a fabulous website. He’s very prolific in his service of information for you, which I encourage you to check it out. Go to CulturalHealthSolutions.com. And he’s recently launched a podcast called Meta Health Podcast, where he uses creative storytelling to teach listeners about healthy metabolism. Stories are the way to go, for sure.
Dr. Mark Hyman:
So, welcome, welcome, welcome, Ronesh.
Dr. Ronesh Sinha
It’s such a pleasure to be here, Mark. Looking forward to our discussion.
Dr. Mark Hyman:
So, years ago, I was with Hillary Clinton, and she was taking me around the Senate, and was trying to get lifestyle medicine covered under Obamacare. And we went to visit Tom Harkin, who was a senator at the time, and she was sharing how, because I was talking to Senator Harkin, who was chair of the Health Committee, about the problem of diabetes, obesity, insulin resistance. And she was like, yeah, as Secretary of State, or when I was a Senator, actually, Senator at the time… I mentioned to her I’d been to India, and I asked the Prime Minister, I said, what do you need help with? Malaria, TB? And he’s like, yeah, yeah, yeah. The real problem is diabetes in our population. You’ve got a billion-plus people in India, and in South Asia there’s a lot more, and for some reason, metabolically, they’re all more susceptible to getting diabetes and prediabetes, even at normal or just slightly overweight conditions.
Dr. Mark Hyman:
And so, why are South Asians at such risk? They make up today one-third of the world’s population, and they have the highest prevalence of heart disease and diabetes. I can’t imagine that 100 or 200 years ago, they were all suffering from diabetes and heart disease, so what is unique about South Asians? What, are there dietary factors, maybe, that are unique to these cultures? I have som ideas, but I want to hear what you have to say.
Dr. Ronesh Sinha
Oh yeah, totally, and you nailed it, and the statistics are overwhelming. I mean, despite comprising that segment of the population, they make up 60% of the world’s heart disease patients, which is pretty astounding. They’ve got quadruple the risk of heart disease compared to other ethnic groups. And the problem here, Mark, is they actually present 10 years earlier as well, too. So, we see a lot of younger-
Dr. Mark Hyman:
They’re younger.
Dr. Ronesh Sinha
Yeah, they’re young. I see individuals in their 20s and 30s presenting with early heart disease, which is astounding. And the way I explain it is, before we sort of get into the fuel source, I like to use a lot of analogies when I teach these concepts. So, I don’t know much about cars, but I’m going to a bit of a car analogy here. And before we talk about fuel sources and food, I’m going to explain to you sort of what the South Asian vehicle is like. If we’re to think of the body of the South Asian vehicle compared to other ethnic groups, and there’s a lot of rich studies out there in the UK and Canada, where they have a large South Asian population, and what we first find is, if you look at the body of this vehicle, there’s a very high fat to muscle ratio. So, lots of-
Dr. Mark Hyman:
Fat to muscle?
Dr. Ronesh Sinha
Yeah, the fat to muscle is very high. So, a lot of fat, and it’s localized around that abdominal area. And I know you’ve done a lot of promotion around the dangers of visceral fat, but we have a relatively much higher proportion of that.
Dr. Ronesh Sinha
What doesn’t get much attention though, Mark, is the low muscle mass. So, when you look at Asians, South Asians specifically, men and females, compared to other ethnic groups, we have the lowest proportion of lean body mass. So, that really-
Dr. Mark Hyman:
Wow. Why is that? Why is that? Is that genetic, or is that just cultural?
Dr. Ronesh Sinha
You know, part of it could be genetic. Part of it is also lifestyle too, because we place a huge emphasis on professional and academic prowess, even early on in childhood. So, part of it is diet. Part of it is culture, as well, too. But that fat to muscle ratio is really out of proportion. So, that’s one part of the body vehicle.
Dr. Ronesh Sinha
And then, like we said, with the fat, you’re right, there are two types of fat, the visceral and the subcutaneous, and this is the tricky part, because that subcutaneous surface fat, that’s what contributes to body weight, right? Most of our mass weight comes from that subcutaneous fat. But we have that stealth, hidden visceral fat that sits in your liver and around your digestive organs, and often when we see patients in the clinic, they present with a normal to low body mass index. And a lot of doctors that know about this, they’re like, hey, you’ve got a free pass. You look great. And these individuals also think they got the lucky genes, so they eat whatever the heck they want, because they’re not overweight, but what they’re doing is, they’re contributing to more of that hidden, stealth visceral fat. So, that’s another part of the sort of surface issue.
Dr. Ronesh Sinha
The other thing is, when you take this car and you look under the hood at the engine, which I know you’ve done a lot of work on mitochondria, and really raising awareness around mitochondria, that’s really the engine that gets the car going. And again, if you compare the South Asian engine, the mitochondria, it’s got a lot of weaknesses. It doesn’t oxidize fat very well. It produces more inflammatory byproducts when it’s exposed to the wrong fuel sources. So, when you look at different ethnic groups, we’ve got this surface body issue, and then the mitochondria are weaker at oxidizing fats, and that can create a lot of different issues. So, that’s sort of the body habitus of the South Asian body. I’ll pause there for a second, in case you want me to clarify anything.
Dr. Mark Hyman:
Yeah. So, there’s a genetic component, where certain ethnicities, even the Chinese are like this, South Asians, have much lower body mass. So, they look thin, but they’re fat on the inside. We call that skinny fat, or TOFE, thin on the outside, fat on the inside.
Dr. Ronesh Sinha
Right, exactly.
Dr. Mark Hyman:
As opposed to tofu, which is not what we’re talking about. And that makes them at much higher risk for this. I’ve seen this so much in my patients, and it’s also challenging, because a lot of the Indian populations are vegetarian, and I’d love your thoughts on the challenges. Because I’ve had patients who were diabetic, type 2 diabetic, on insulin, struggling, and within literally days, they’re off insulin, they’re off their medications. Their diabetes in a few weeks is literally reversed. And that is usually by restricting every type of carbohydrate. So, that’s grains, beans, and obviously sugar.
Dr. Ronesh Sinha
Yeah.
Dr. Mark Hyman:
And so, in the case of South Asians, a lot of the controlled preferences are for vegetarianism, where there’s a high amount of starch, a high amount of rice, a high amount of bread, a high amount of sugar. How do you navigate that? Because I had a patient just, it was really hard to help her, because what could I have her do? She tried protein shakes, nuts, and it was just, she was very resistant to it. And I know I could have fixed her overnight, but she really struggled.
Dr. Ronesh Sinha
Absolutely. That’s a big cultural part of it. And you’re right. The early work I did, I highlighted that most South Asians are actually not true vegetarians, they’re grain-atarians, or they’re carb-atarians, right? Because the proportion of vegetables that they’re consuming-
Dr. Mark Hyman:
Carb-oholics, you mean? Carb-oholics?
Dr. Ronesh Sinha
They’re carb-oholics, right? Because if you basically use a general term, vegetarian, for all people that don’t eat meat and fish, you miss all the nuances, right? If you look at a typical Western vegetarian diet, a healthy form of that, versus a traditional Indian vegetarian diet, there’s tremendous differences in that.
Dr. Ronesh Sinha
Just to give you a quantitative approach, if you were to quantify it… And again, I think you and I both share one thing, is we like to personalize diets for different individuals. So, we’ll carb count for everyone, but definitely, if you take a population that, again, if we’re thinking of the fact that we’ve got less horsepower in our engine genetically, and carbs are a high-energy fuel source, we’re overwhelming that engine on a regular basis.
Dr. Ronesh Sinha
If you want to get quantitative about it, a lot of my patients, for example, they’ll thrive if they can bring their carb intake down to 100 grams per carb per day. But my typical South Asians and East Asians, they’re consuming 400 to 500-plus grams of carb. And I tell them, the carb itself is maybe benign, if it’s rices and starches, if you are Michael Phelps, or if you are an Olympic-level athlete with a V12 engine under your hood. But you’ve got more like a minivan or a lawnmower engine, and we can’t flood it with that sort of carbohydrate.
Dr. Mark Hyman:
Vitamix engine.
Dr. Ronesh Sinha
Right, exactly. We don’t have that sort of horsepower. We can build that up, and we’ll talk about that later, but we just don’t have that.
Dr. Ronesh Sinha
So, one paradigm that I use to really-
Dr. Mark Hyman:
Wait, wait. So, what you’re saying is, genetically, is mitochondrial function less in South Asians?
Dr. Ronesh Sinha
I will tell you this, it’s a combination. So, genetics is a part of it, but then the lifestyle is key. So, when we talk about this car vehicle, I tell people, the prototyping and designing happens with the parents, right? So, even before conception happens, if mom and dad are both insulin-resistant, and they’re sedentary, what happens is they’re already insulin-resistant, and that’s going to get transmitted into pregnancy. And that’s why in a lot of parts of India, and even in the US, South Asians have 40-50% gestational diabetes. They’re already hyper-insulin-making, and they’re transferring that to the placenta.
Dr. Ronesh Sinha
And the sad thing is, you mentioned skinny-fat. When you look at the South Asian’s fetus for the newborn, they’re already skinny-fat. They’ve got less, basically, muscle mass, and a tiny little potbelly. So, they’re already a mini-me version of what they’re going to be later on in adulthood. So, that’s a big problem. That design happens early on. So, part of it is genetics, but the other part is the lifestyle before and during pregnancy. A lot of the health education I’ve done for tech companies in the community is, how do you design a healthier pregnancy?
Dr. Ronesh Sinha
Because I’ll tell you one thing that really makes this engine much worse. VO2 max, which is a marker for mitochondrial performance, that’s something the parents can influence. So, I tell parents that if you’re planning to get pregnant, you’ve got to get fit for this pregnancy. Both of you need to be physically fit. But most South Asians are so sedentary that they come into this pregnancy unfit, and they’re going to have basically an offspring that’s going to have a low VO2 max and a low horsepower engine.
Dr. Ronesh Sinha
But my patients that take this to heart, their kids don’t have that. Their mitochondria is stronger. It can withstand a little bit more carbohydrate load. But this cultural, epigenetic, intergenerational issue is really causing that engine to be much less capacity, so that’s a big problem.
Dr. Mark Hyman:
That’s huge. And really, it reminds me a little bit of the Pima Indians, who 100 years ago, 150 years ago, were thin, were fit. Their diet was about 80% carbs, but it was like acorns and nuts, and things that they grew. And there was no diabetes. There was no obesity. And now, Pima are probably the second-most obese population in the world, after the Samoans, and their life expectancy is 46. 80% get diabetes by the time they’re 30, and we’re seeing type 2 diabetes in three-year-olds in that population.
Dr. Ronesh Sinha
Incredible. I think, by the way, I want to pause on that. I wanted to connect the Pima Indians, because there’s another characteristic we’re seeing evolutionarily evolve in that, and that’s the type of fat that South Asians and Pima Indians actually have. We have less of the brown adipose tissue. That brown adipose tissue, as you know, is the mitochondrially active fat tissue that can actually burn carbs and glucose, and Asians, populations that come from more equatorial regions, they have less brown adipose tissue, and that makes sense, because if I’m out in the field, I’m out in the sun, and I’m toiling and I’m laboring, I don’t want to generate extra heat, right? That’s going to be a dehydrating factor. But as you take these individuals out of their equatorial climates, and you put them in temperature-controlled rooms, and then all of the sudden, you flood them with this diet, you see a huge impact from that. And as I said, brown fat, it can contribute 15-20% to your baseline resting metabolism. So, that’s a major overlap that we’re seeing.
Dr. Mark Hyman:
That’s interesting. So, there’s less brown fat in these populations.
Dr. Ronesh Sinha
There’s less brown fat, yeah. I’ve got brown skin, but I’ve got less brown fat. Unfortunately, they don’t correlate.
Dr. Mark Hyman:
Amazing. And the thing that just occurred to me, Ronesh, is that being South Asian and aging are very similar, in that as we age, the population loses muscle and becomes fat, and you marbleize your muscle. It looks like a rib eye instead of a filet mignon. And that’s the source of poor metabolic health, which means prediabetes, diabetes, hypertension, heart disease, cancer, everything else. And it’s 100% fixable and preventable. I actually, as I’ve gotten older, I’ve gotten more and more muscle, because I’ve realized that muscle is the neglected organ.
Dr. Ronesh Sinha
Oh, so true.
Dr. Mark Hyman:
It is the key to health. And it’s not just about looking like Arnold Schwarzenegger, it’s really about creating metabolically healthy muscle, which is the main sink for your calories and your food, and if that’s not working efficiently, you’re in trouble. And what happens also to these people is, they have a low VO2 max, which is basically the amount of oxygen you can burn per minute, which is the rate limiting step in your metabolism. So, you can only burn as many calories per minute as you can breathe liters of oxygen, or run liters of oxygen per minute through your mitochondria. And the mitochondria in these people are impaired for a number of reasons. One, the diet itself impairs the mitochondria. Two, it sounds like genetically, there’s some issues there. And that we know even in the PCG1 receptor, there’s challenges genetically, even in first degree relatives of type 2 diabetics. So, they may have 50% slower metabolism to start with, and I think this is a really prevalent condition in South Asians. And so, we’ve seen the aging phenomenon the same as the phenomenon you’ve seen. So, what we’re saying her applies not just to South Asians. It applies to everybody.
Dr. Ronesh Sinha
Agreed.
Dr. Mark Hyman:
And there’s a lot of people walking around who are skinny fat. They think, no, I’m good. I can eat my sugar, and I can eat this and that. I don’t gain weight. Well, that’s not the key metric. It’s really a much deeper metric.
Dr. Ronesh Sinha
I love what you brought up. You know, that age-related muscle loss, which we call sarcopenia, at a molecular level, I call it mitopenia, because if you lose muscles, you’re losing mitochondria as well, too. And those Indians, if you lose horsepower, you’re not going to be able to tolerate the carbohydrates, an adequate amount of that. And so, one way I bargain with my patients, whether they’re of Asian Indian descent or anything is, if you want to eat rice, you’ve got to sort of earn the right to eat that rice. Because the fact is, you’ve got to squat for your rice. You’ve got to walk for your rice. You’ve got to do some physical activity to earn that, because otherwise, if their minivan’s sitting in the garage and it’s not doing anything, your body’s not going to tolerate that.
Dr. Ronesh Sinha
And the beauty of that, and you know this, Mark, firsthand, is when you get people more aerobically active, more physically exercising, all of the sudden, they can handle a little bit more of the carbohydrates. The same ones that cause me to get insulin resistance now is a fuel source after I work out. It doesn’t have the same impact. So, I think that gives our patients some hope that this is not a banned food like the fructoses and the other processed foods out there. We can reintroduce it gently to the diet as you upgrade your metabolism.
Dr. Mark Hyman:
It’s true. I mean, honestly, I love to eat, which is why I like to exercise. But I’ll go for a two-mile bike ride, and I’m like, whoa, great. I went for a 15-mile bike ride the other day. I burned 2,400 calories. I’m like, yippee, I get to eat more food today.
Dr. Ronesh Sinha
Right, totally, totally. I’m the same way. And I don’t have the willpower. Yeah, totally.
Dr. Mark Hyman:
I was so happy. It felt so great. So, Ronesh, your work is pretty remarkable in calling this out and talking about the cultural differences in health, and that’s why we often see health disparities in other populations, like Native Americans, African Americans, Hispanics, and of course in South Asians. So, you had this problem too, right? You evolved metabolic syndrome, and your triglycerides were high, and your HDL was low. What were you living like? What was your diet, and what was the story around that?
Dr. Ronesh Sinha
Yeah. You know, I’ve been a lifelong devotee of healthy practices, and even back then, when I started my practice in Silicon Valley, I was following the standard dietary guidelines. I was exercising four or five days a week. But what I was doing was-
Dr. Mark Hyman:
Oh, wait, wait, that was the problem. You were following the standard dietary guidelines.
Dr. Ronesh Sinha
That’s exactly right. You nailed it right there, right? And my standard dietary breakfast was pretty starchy, with a lot of fruits and oatmeal. I’d have a whole wheat bread sandwich for lunch. So, it was a lot of those healthy carbs, that were so-called healthy carbs, that were really overwhelming my system, and then also, my exercise was really a lot of HIIT training, a lot of high intensity interval training, and not really that steady more longer rate, sort of cardio. And as a result of that, I started seeing my patients developing insulin resistance. I was giving them advice-
Dr. Mark Hyman:
You were telling them to do what you were doing.
Dr. Ronesh Sinha
But then I was getting insulin resistant too, so I’m like, okay, so this is not going to work out. How can I be a health leader if I’m developing the same conditions as my patients? And then, that really caused me to dig deep into the literature. I had the benefit also of being mentored by Jerry Reaven, who actually coined the term metabolic syndrome.
Dr. Mark Hyman:
Oh, really? Yeah, syndrome X.
Dr. Ronesh Sinha
So yeah, I used to drop by his office in Stanford, and he really helped highlight this triglyceride, HDL, this issue, and he was really such a pioneer. He literally told me that sometimes he doesn’t get invited to conferences because his metabolic syndrome criteria doesn’t include LDL, right? He kind of nailed the triglyceride, HDL, insulin resistant access.
Dr. Mark Hyman:
I agree.
Dr. Ronesh Sinha
And so, I took that learning and then really dug deep, and then made changes in my body, which I basically translated to my patients. But that was eye-opening. That was over a decade ago. So when I saw that, I’m like, okay, standard dietary guidelines, the websites and resources I’m giving to my patients are actually making them worse. They’re making me worse, as well. And that really kind of led me to really create the resources they need to really address this problem.
Dr. Mark Hyman:
That’s amazing. I have a lot of Indian patients at my practice, and I see exactly what you see, and I’ve often wanted to create a cookbook that’s like a high-fat, low-carbohydrate, vegetarian Indian cookbook.
Dr. Ronesh Sinha
Oh, Mark, I would love if we did that. People ask me to write a cookbook. I have no interest in that, so if you did that, I would love to promote that. Please put that on your long to-do list.
Dr. Mark Hyman:
A friend of mine was an Indian woman, and she was going to get her mother to do it, but she never did.
Dr. Ronesh Sinha
Right.
Dr. Mark Hyman:
But it’s challenging. So, what do you tell your patients? Because if they’re already kind of set up with a deficit, because of genetics, then it’s a little bit frustrating. How do you help them?
Dr. Ronesh Sinha
We do two things simultaneously. The first thing, I have a bit of a clever mnemonic that I use with my patients, called CARBS, so they can basically just identify the framework for the sources of their carbohydrates. So, the C in carbs stands for chapati, which are flat Indian breads, okay? The A is aloo, which are starchy potatoes, because most of the vegetables of concern are a lot of starchy potatoes and samosas. The R is rice. The B is beans and lentils. And the S is sugar and sweets. So, when they have that framework-
Dr. Mark Hyman:
I love that!
Dr. Ronesh Sinha
It works perfectly.
Dr. Mark Hyman:
I love that. I love that. Chapati, aloo gobi, I get it.
Dr. Ronesh Sinha
Right, rice, beans, and sugar and sweets, right? So, if you have that framework, and I’m not telling them they’re going to eliminate all of those, but let’s have just small portions of that with each of the meals. Maybe one meal’s going to have a little bit of rice. Maybe we’ll have some lentils with that, but then, where are our protein sources coming from? Like, how do you really compose a meal so they’re not 100-150 grams of carb per meal, which is what I see in my vegetarians, but how do we mix proteins and healthy fats into it? And this is the hopeful part, is a lot of the fats and oils in foods that we thought should be banned in the Indian diet, they’re actually now becoming healthy, right? A lot of the paleo, primal movements, they’re using a lot of our traditional healthy fats.
Dr. Mark Hyman:
You mean like coconut, or ghee?
Dr. Ronesh Sinha
Exactly. Coconut oil. Ghee, for people who tolerate it. So, one trick I teach them, for example, is when you have starches that are not mixed with other ingredients, that’s when the problem happens. If you love rice, eat it more like biryani or fried rice style, where you mix vegetables into it, nuts and seeds, healthy oils and fats, and you’re going to see, that’s going to dampen the glycemic impact. A lot of people are making chapatis or flatbreads, but they’re adding eggs to it, like egg bharta, or they might mix almond flour into the batter. So, I teach them how to make higher-protein flour flatbreads.
Dr. Mark Hyman:
Yeah, like chickpea flour, almond flour.
Dr. Ronesh Sinha
Exactly right, yeah. And you get full of having one, or maybe two max, and your glycemic stability is much better. So, dilute out the effects of that starch by mixing the vegetable, proteins and fats. And the Indian diet has plenty of those. So, when they feel miserable about that, I really add that diversity, and they feel fuller, their energy is better, and oh, by the way, their net carb intake has gone down by 30, 40%. And then simultaneously, we do have to upgrade their physical activity levels, and really work on the things you talked about. We’ve got to make up for the loss of lean body mass, muscle. We’ve got to gently elevate that VO2 max.
Dr. Ronesh Sinha
But I start with food first, because immediately, they start to feel better. And as you know, the numbers are magic, right? Within a month, we see triglycerides drop, and if they see that metric… We’re very metrically motivated, as a population. You see those numbers go down, and you’re like, okay, what do I do next to get the numbers even better than that? So, that’s one framework that I use.
Dr. Mark Hyman:
Yeah. No, that’s powerful. And you said something that’s very provocative, and I think I want to dive deep into it with you right now, which is the fact that in the criteria for metabolic syndrome, LDL doesn’t matter. Which seems to be the only thing that matters to traditional doctors and cardiologists. And the thing that matters is the ratio of triglycerides to HDL, which is, they call it the good cholesterol, but it’s just one of… LDL isn’t bad, it just has a different role.
Dr. Mark Hyman:
And the striking thing to me is that there’s so much nuance to understanding lipid profiles, rather than just the LDL, or total all, or even the HDL triglycerides. And work with Dr. Ron Krauss has underscored the importance of the lipid particle number and the size. So, it’s not just the weight of your cholesterol, which is what we measure, but the actual number of total particles and the size.
Dr. Mark Hyman:
And you can’t really look at cardiovascular disease without looking at all of the picture, here. And what’s unfortunate is that a lot of medicine gets practiced without ever diagnosing metabolic syndrome. 90% of the time, it’s not diagnosed. And yet, it probably affects, I would say, 88% of the population. Think about it: you’ve got a condition that affects nine out of 10 Americans, and doctors miss it almost every time. And they don’t know how to treat it because there ain’t no drug for it. I mean, metformin is something they give, but it doesn’t really work that well. And so they go…
Dr. Mark Hyman:
It’s like that patient I had whose blood sugar was creeping up, and it was like 115. I’m like, hey, did you see your doctor and get yourself checked out? And she’s like, well, yeah. I said, what did he say? Well, we’re going to watch it. I said, watch for what? Watch ’til I get diabetes, and then they’ll give me treatment. And I’m like, oh god.
Dr. Mark Hyman:
So, I want to sort of dive into this framework of how do we think differently about lipids? What is your approach to lipids? And what should we be thinking? And does everybody need a statin?
Dr. Ronesh Sinha
Yep, great. A lot of topics, here, but let’s tackle this together. Let’s move from cars to boats, because I think boats are the best analogy for explaining lipids. When you think about the lipoproteins, the LDL particularly, they’re really boats that are floating through your blood vessel, and they carry cholesterol and energy to your cells, which is a great thing to do, right? They’ve been demonized so much, but they’re so essential for our body to function properly.
Dr. Ronesh Sinha
When you look at LDL… When I say that LDL is not part of the metabolic syndrome criteria, I’m not saying that LDL doesn’t matter. LDL has to crash into the vascular wall, the blood vessel wall, and cause inflammation to cause heart disease. But on your regular blood test, we’re measuring the wrong part of LDL. So, if you think of these lipoprotein boats, you nailed it. You said the particle numbers and the size are more factors. But when you look at a standard lipid panel, it’s not measuring those factors. It’s just looking at how much cholesterol cargo is that boat carrying?
Dr. Ronesh Sinha
And here’s the part that misleads people, because I don’t know how many people I’ve seen that had an early heart attack, and they’re told by their doctor that their LDL looks fine. The problem is, the more insulin resistant you are, the higher your triglycerides go, and when triglycerides are high, in most people, they push your LDL down. Because what happens, these small particles, they carry less cargo, so that’s going to make your LDL-C on a standard cholesterol panel low.
Dr. Ronesh Sinha
So, when I had triglycerides above 300, my LDL was like in the 70s or 80s, and my doctor at that time told me, thank god your LDL’s fine. But what he didn’t recognize is that my LDL-C was low, but it’s because I had these small particles. So, anybody that’s got a triglyceride, even if you don’t have access… Luckily these tests are accessible, and they’re affordable now. But even without doing that, once our triglycerides climb above 130, 140, 150, 80-90% sure that your LDL particle numbers are high.
Dr. Ronesh Sinha
And in fact, what I started teaching doctors in my group is, if you make the right lifestyle changes and you reverse insulin resistance, the LDL’s actually going to go up on a standard lipid profile, because now what’s happening is, the LDL’s going to go up because you’re generating larger boats, and they can carry more cholesterol, but that’s a good thing, because you want less boats carrying more cholesterol than these tiny boats carrying small amounts.
Dr. Mark Hyman:
So, just to clarify what you’re saying for people, the total number you going to on the cholesterol panel goes up, but the particle number goes down.
Dr. Ronesh Sinha
Right?
Dr. Mark Hyman:
So, the actual problem gets better. It’s not that your cholesterol is getting worse. It’s actually getting better, it’s just how we look at it.
Dr. Ronesh Sinha
Exactly.
Dr. Mark Hyman:
I mean, I’m much more worried about someone with a cholesterol of 150, an LDL of 70, an HDL of 30 and a triglycerides at 300 than I am of someone who’s got a cholesterol of 300, an HDL of 100, and an LDL of 150.
Dr. Ronesh Sinha
Exactly.
Dr. Mark Hyman:
I’m much more worried about that person who’s got a cholesterol of 150. That’s something that traditional medicine just kind of misses.
Dr. Ronesh Sinha
It does. And you know, the other element of the total cholesterol, why it goes up if you’re doing the right thing, a lot of patients, is the HDL goes up, right? So, all of the sudden, LDL’s going up, HDL’s going up. So, that’s why ratios are key, and we hinted on this, but I tell people, just forget absolutes, and just look at triglyceride to HDL ratio. That’s a key number for insulin resistance.
Dr. Ronesh Sinha
Now, having said that, obviously if your total cholesterol is above 300, yeah, your LDL level, regardless of size, is probably too high. But you know, for most people, if you stick to ratios, that’s a far more powerful number to look at.
Dr. Mark Hyman:
Yeah, I think that’s important, and the triglyceride to HDL ratio should be ideally less than one, or about one. If it’s more like two or three or four, if your triglycerides are at 300, and your HDL is 30, that’s a ratio of 10.
Dr. Ronesh Sinha
Oh, yeah, if it’s in double digits… Yep, exactly.
Dr. Mark Hyman:
So, I think those are the challenges, and we don’t know often what to do with these people. How do we fix their lipid profiles? And so, what do you do in terms of statins for these patients?
Dr. Ronesh Sinha
Good point. Again, if they’ve got the insulin resistant profile, we’ve got to focus on lifestyle first, because even if you put them on a statin and they’re high-risk, the incremental benefit is still small, relative to making lifestyle changes. I mean, I’ve got loads of patients who are statins that had their first MI, right? Because you know, one of the problems with statins… We can talk about a lot of issues with statins, but when patients go on it and they see their numbers magically transform, often they think it’s a free pass to go back to whatever they were doing.
Dr. Mark Hyman:
Yeah!
Dr. Ronesh Sinha
I’ve seen that it does have a negative impact on lifestyle. So, I sometimes put the statin a little bit in the background, and we definitely focus on lifestyle first. But having said that, the other test I often have to do in these patients, because they’re so high-risk, is I do a coronary calcium scan. That’s CT scan, to look at the blood vessels, to see if there’s early signs of plaque.
Dr. Ronesh Sinha
And in those patients that are already developing pretty large plaque sizes, I do get concerned. These are patients where statins probably do make sense. I might prescribe it in those cases. But I want a lot more data before I put patients on statins. What’s their inflammation status? What’s your CRP? What are the advanced lipid profiles showing, before we jump into sort of putting everybody on a statin itself.
Dr. Mark Hyman:
Yeah. It’s important what you just said, because in the JUPITER trial, one of the largest trials on statins, they found that the if the LDL was high and the CRP was high, which is inflammation, statins helped. If the LDL was high and the CRP was normal, they didn’t help.
Dr. Ronesh Sinha
Yep.
Dr. Mark Hyman:
So, it’s really much more nuanced than we typically think about. And one of the challenges of statins is that it affects insulin resistance, and it impairs mitochondrial function, and may affect your risk of diabetes. And there seems to be, in some studies, up to 80 future risk of diabetes. How do you reconcile that in this population so at risk for diabetes?
Dr. Ronesh Sinha
Yeah, good point. I mean, basically you’ve got to weigh both arms, here. And you’re right, because they’re insulin resistant, we don’t want to put them on a drug that’s going to make the insulin resistance worse. But at the same time, if they’ve already got elevated CRPs, they’ve got early signs of plaque, then you’ve got to weigh those two.
Dr. Ronesh Sinha
I have had some patients that we did an initial trial of statins, we got their lifestyle in shape by four, six, nine months, and we often took them off the statins. That’s the other, I think, misconception, is a lot of doctors and patients feel like onc you’re on a statin, it’s a lifelong sentence, right? But sometimes you can mitigate risk temporarily, make some changes, and then we can-
Dr. Mark Hyman:
Yeah, I do it all the time.
Dr. Ronesh Sinha
I mean, just think about that. It’s like a novel concept in traditional medicine, can we take people off their drugs? But it’s something that we should be addressing every time we see our patients.
Dr. Mark Hyman:
Yeah. It reminds me of a patient I had where his numbers after the lifestyle changes were better. He’d had a heart attack, and he had metabolic syndrome, and we aggressively treated him. And after he changed his diet and lifestyle, his cholesterol numbers overall were better than they were on the statin.
Dr. Ronesh Sinha
Look at that, right?
Dr. Mark Hyman:
Which is amazing. So, I think people underestimate. And also, it’s variable, depending upon the person. I want to come back to something you said that I think is really important, that we just sort of brushed over, which is the change in the oils in the diet.
Dr. Ronesh Sinha
Yeah.
Dr. Mark Hyman:
So, traditional oils in India are ghee, which is clarified butter, with the milk solids taken out, and coconut oil, right?
Dr. Ronesh Sinha
Mm-hmm (affirmative).
Dr. Mark Hyman:
Except they changed, to what?
Dr. Ronesh Sinha
Well, unfortunately, it changed to the vegetable oils, the seed-based oil, the omega-6s, the processed oils, which are so much more pro-inflammatory, right? So, if you look at my grandmother, who lived to be in her mid-80s, and her sisters, it was basically ghee, coconut oil, was a standard part of their diet, and they were making that at home basically, right? That’s very different from the processed oils that are out there. And even though ghee and coconut oil are sort of back in fashion, a lot of my patients are still buying them from Indian stores or other places, where they’re stored in jars and unstable environments. They’re really not like the homemade ghee.
Dr. Mark Hyman:
They’re funky.
Dr. Ronesh Sinha
Yeah. So, I wouldn’t even say that all ghee and coconut oil is benign. It really depends on the sourcing of that. But yeah, I’d say that the transition to these seed-based oils, major inflammatory factor. So, many of my patients, even if they’ve gotten the carb thing right, they’re doing everything right, I still see that they’re inflamed based on symptoms or C-reactive proteins. But when they do the oil change methodically, after a few months, we start to see CRPs and a lot of inflammatory symptom, eczema, other things, start to disappear.
Dr. Mark Hyman:
Really? So, when you change the oils out, when you give people an oil change…
Dr. Ronesh Sinha
An oil change, literally, yeah.
Dr. Mark Hyman:
You literally change all these health symptoms, their lipids.
Dr. Ronesh Sinha
Yeah. It’s part of my… Initially, that’s not something that I focused on, but I kind of call it the three Cs. The carbs, the cooking oils, and circadian rhythm, which we can talk about. But those are three fundamental things that we need to sort of focus on in the population to see inflammation and improved health from the dietary standpoint.
Dr. Mark Hyman:
And people push back. They go, well, coconut oil and ghee are saturated fat, and those cause heart disease, and these people are at risk for heart disease, and it’s going to cause their cholesterol to go up. How do you answer that?
Dr. Ronesh Sinha
What I would say is, again, you’ve got to go by the numbers, right? As much as you can look at all the data, a lot of my patients who want to hold onto those fats, I’m like, you know what, let’s do a two or three month trial. We’ve got your baseline numbers. If you have a little bit of ghee and coconut oil, let’s see what happens to your lipids and your insulin resistant numbers. If they’re better, I don’t care what the media and mainstream medicine’s saying. You’re better, your numbers are better, so stick to whatever you’re doing.
Dr. Ronesh Sinha
Now, having said that, I would tell you, Mark, that I am seeing some of my patients that are going hog wild on ghee and coconut oil. They’re on a very high sat-fat keto diet, and often I’ve seen their weight and their LDL go skyrocket. And what I tell them in that case is, again, coming back to my car analogy, is if you’re not exercising, you’ve got a low-horsepower engine, but you’re putting jet fuel into it, right? I mean, even high sources of saturated fat can raise LDL and raise body weight if your mitochondrial engine is low performance. So, you’ve got to sort of upgrade the engine or downgrade that.
Dr. Ronesh Sinha
But the other thing is, I do like them to diversify fats. I don’t think the should be doing all sat fats. Can we add some monounsaturated and some omega-3s?
Dr. Mark Hyman:
Olive oil, fish.
Dr. Ronesh Sinha
Because as much as I find sat fat to be… Exactly, olive oil and fish. I mean, sat fat I think is fairly cholesterol neutral, but it doesn’t have a lot of data, unless you’re aware of it, that it’s truly heart protective. It doesn’t compare to the monounsaturated fat, the Mediterranean trial. So, I’d want to diversify that as much as possible.
Dr. Mark Hyman:
I think that’s right, and one of the key things that I think it’s important that people understand is that in the context of a carbohydrate-rich diet, saturated fats can be deadly. Can be deadly.
Dr. Ronesh Sinha
Exactly right.
Dr. Mark Hyman:
So, if you eat them without eating all the starch and sugar, and cut all the flour and sugar out of your diet, or most of it, you can tolerate it better. But if you combine them, it’s really bad. Because if you’re really insulin resistant, and you’re eating all this saturated fat, it can be a problem if you don’t change your overall diet.
Dr. Ronesh Sinha
And that’s why, Mark, I mean, you mentioned the point, this is why the studies are so misleading, right? Because the people that are consuming the saturated fats and developing heart disease at the large trials, they’re consuming loads of sugars and starches. So, you don’t uncouple those in the traditional trials, so people don’t realize this is a starch-dependent disease, but the fats only get blamed for it.
Dr. Mark Hyman:
Yeah, exactly. That’s right. And then, the other thing is that there’s a lot of heterogeneity in the population. A lot of variation in response to saturated fat or diet.
Dr. Ronesh Sinha
So true.
Dr. Mark Hyman:
So, what you just sort of alluded to the fact was that some people, you give them coconut oil and butter, and their numbers drop like a stone, and they lose weight and they’re healthy. Other people, it’s the opposite. And so, how do you begin to understand that? Well, the reason is that we’re all different. We’re all different genetically, metabolically, and tolerate different levels of starch and fat, and the kinds of fat and starch. So, you have to find out, what is your own…
Dr. Ronesh Sinha
Threshold.
Dr. Mark Hyman:
Personalized approach to dealing with diet and cholesterol.
Dr. Ronesh Sinha
Exactly. Exactly. So true.
Dr. Mark Hyman:
Yeah. So, when someone comes in with a cholesterol panel, and they’ve got problems, what do you tell them? What is your recommendations around how to fix their cholesterol, what lifestyle changes they should do, and how to think differently about it?
Dr. Ronesh Sinha
Yeah, and again, with personalization, you’ve got to look at the nuances of the cholesterol panel. So, if it is somebody with those insulin resistant factors, like the high triglycerides, and/or the low HDL, then you know this individual is insulin resistant, meaning they’re less carbohydrate tolerant. So, I’m really focused in on that carb paradigm. How do we really dilute the effect of the starches? How do we increase activity levels? And that’s going to be nailing that.
Dr. Ronesh Sinha
Now, some patients, like I said, they might have very high LDLs, or a combination of all three, high triglycerides, low HDL, and the high LDL. And in those patients, we do have to be a little bit sensitive to the amount of sat fat in the diet, so then we’d modify that, but we also want to elevate the amount of high fiber-rich foods that can bring down the LDL. I get pretty good results, and maybe you see the same, with even adding more fermented foods. If you improve gut microbiome health, that can actually help your body get rid of that LDL cholesterol and lower inflammation as well. And that’s a traditional part of the Indian diet and the Asian diet, too. There are fermented foods that are part of it.
Dr. Mark Hyman:
Like yogurt, or…
Dr. Ronesh Sinha
Yeah, exactly. The mango pickles and things. But a lot of times, they buy it from the Indian grocery store, and they’re soaked in seed-based oils, so then you’re trading one problem for the other. But traditional fermented foods can be very valuable for that. So, that’s sort of how you tailor the lipid profile and do the lifestyle sort of accordingly.
Dr. Mark Hyman:
Right, because this problem, diabetes in Asia and in China and in India has totally changed. I mean, I don’t know exactly the data for India, but in China, they went from like one in 150 people having diabetes to like one in 10.
Dr. Ronesh Sinha
Over such a short period of time. It’s astounding.
Dr. Mark Hyman:
Yeah, just over a couple of decades. So, that’s staggering. So, that makes you realize it’s environmental and lifestyle-related.
Dr. Ronesh Sinha
Yeah.
Dr. Mark Hyman:
And in terms of the patients you see, and your framework, it’s like this juggernaut that’s happened almost overnight. I mean, even when we graduated from school… I don’t know how old you are, but I’m older. But
Dr. Ronesh Sinha
I turned 50 last week.
Dr. Mark Hyman:
50? Okay, well, I’m 60-something.
Dr. Ronesh Sinha
There you go. You’re a good-looking 60.
Dr. Mark Hyman:
Yeah, right. And there wasn’t this level of diabetes. We just didn’t see it. And what’s interesting is, this whole idea of comorbidities is such an irritant for me, because oh, you have high blood pressure, you’ve got high cholesterol, you’ve got high blood sugar, like they’re all separate things. They’re not, right? High blood pressure is one of the biggest killers, but what causes high blood pressure?
Dr. Ronesh Sinha
Right. Insulin resistance is such a central factor to that, right?
Dr. Mark Hyman:
Right.
Dr. Ronesh Sinha
So, these individuals who are overweight and insulin resistant, they’re retaining more sodium and fluid, they’ve got high uric acids. That’s a part of insulin resistance, and that causes blood pressure to go up. Just putting people on a DASH diet and telling them to limit salt, that’s not enough. You’ve got to really address the insulin resistance. We now know hypertension is an inflammatory condition. So, we keep coming back to this, but if you don’t lower inflammation, it’s not going to help. And I’ll be honest, in my patients, I’m actually seeing some teenagers with high blood pressure, which I’d never seen before.
Dr. Mark Hyman:
Yeah, yeah, for sure.
Dr. Ronesh Sinha
And a lot of it is related to sleep and stress, too, so that circadian rhythm is a huge factor. But yeah, I mean, you nailed it. The other thing is-
Dr. Mark Hyman:
Wait, just to reinforce what you’re saying…
Dr. Ronesh Sinha
Yeah, please do.
Dr. Mark Hyman:
Is that one of the biggest causes of high blood pressure is insulin resistance, and it’s undiagnosed. We call it essential hypertension, which means essentially, we don’t know what causes it, but we do. But we do, actually, now. Maybe when it was named we didn’t know, but now we know. And yet, doctors don’t address high blood pressure by addressing insulin resistance.
Dr. Ronesh Sinha
Yeah, so true. I know. I mean, to us it seems to simple, right? It’s like a fundamental process which has all these branches that link to all the typical disorders that we see, but people are really not putting the pieces together. So hopefully, and I think that’s starting to change now, with the information getting out there, but we’ve got to be more proactive, so it just becomes mainstream.
Dr. Mark Hyman:
Yeah. Well, this is fascinating. I want to change tacks a little bit, talk about a term that you came up with which is fascinating to me, and I think it’s accurate, which is what you call a transmissible metabolic disorder, a contagious sort of metabolic disorder, which is COVID. And we think of COVID as an infectious disease, but actually, is it a lifestyle disease? And how, and why?
Dr. Ronesh Sinha
Right. So you know, basically with the COVID-19 pandemic, I’ve kind of just added a different spin to my mainstream message already, just because of the data that’s shown a profound link between COVID-19 and insulin resistance. So both, if an individual has insulin resistance already, we know from the data that their risk of a severe COVID-19 outcome is so much higher. The obesity, even the high triglyceride HDL has been independently shown to be a risk factor. So, we know that from that standpoint.
Dr. Ronesh Sinha
Now what we’re finding too, Mark, is individuals with a COVID-19 infection that have existing diabetes or glycemic control gets worse, but we’re also seeing individuals who had no detectable signs of insulin resistance actually develop insulin resistance after COVID-19 infection. Now, most of the studies have been done in more severely hospitalized patients, but we are anecdotally seeing now that even in the outpatient, less complicated cases, there are some insulin resistant features that are showing up in individuals that didn’t have that before.
Dr. Ronesh Sinha
So, one of the analogies that I use is, it’s almost kind of like gestational diabetes, where pregnancy can unmask underlying, hidden diabetes. COVID-19 looks like, in a certain segment of the population, that stressor and inflammatory load to the body is unmasking a potential underlying tendency towards insulin resistance, or possibly even causing it de novo, because it can invade the beta cells of the pancreas, it can really diminish insulin production, it can affect the mitochondria, it can do so many insidious things. And that’s why I use the word transmissible metabolic disorder, because even after the infection is cleared, it can potentially cause some lasting metabolic changes in the body that we need to be aware of.
Dr. Mark Hyman:
Yeah. Fascinating. So, you talk about this whole idea of “Covesity.” What is that, and how is body fat and visceral fat linked to the severity of COVID?
Dr. Ronesh Sinha
Yeah, I mean basically, I think the term cytokines… If one thing has happened with COVID-19, you know, I try to be as optimistic as possible, but I think people’s education around the immune system has been elevated as a result of this. So, a lot of people know about the term cytokines, because they’re aware of cytokine storms. But if we can be more specific about inflammation, and limit to the cytokines, which are the inflammatory messaging from our immune system, we realize that that belly fat, that visceral fat that we talked about, it’s a storehouse of chemicals, especially cytokines, which can really make our bodies more flammable. So, when they get a COVID-19 infection, their risk of having a severe outcome is much worse.
Dr. Ronesh Sinha
So, with many of my patients that are worried about COVID-19, I’m like, can we get the waistline down through lifestyle changes, so we can lower that total, cumulative cytokine load in case you’re to get a COVID-19 infection, which unfortunately, the likelihood is getting higher and higher as these variants come out. But really, that’s the key part, is that visceral fat is connected to that cumulative cytokine load.
Dr. Mark Hyman:
It’s crazy. And what really shocked me was the data that came out of Tufts, from Dariush Mozaffarian, where they found that they could attribute 63% of all hospitalizations for COVID to diet.
Dr. Ronesh Sinha
Yeah.
Dr. Mark Hyman:
So, I’m going to say that again. 63% of all the people in the hospital from COVID, it’s not because of COVID, it’s because of what they’re eating, and how what they’re eating has caused them to have insulin resistance, which basically lets them be pre-inflamed. And so, when the COVID hits, it’s like putting gas on a fire, and the inflammation goes crazy, and that’s what ends up putting them in the ICU, or even killing them.
Dr. Mark Hyman:
So, this is such an important moment, and you talked about how you’re beginning to see this as an opportunity for how we kind of have to rethink our approach to the next pandemic, or even this pandemic. Maybe we, as a nation, need to focus on how do we address this. So, what are you thinking about that?
Dr. Ronesh Sinha
I mean, you know, Mark, I think this is my frustration. I don’t think the media and public health agencies are focusing on this enough. You might see an anecdotal headline here or there, but you’re obviously taking this on from the food standpoint, and I laud you for the work you’re doing around this, but if we don’t sound the alarm bells now, that COVID looks like it’s become more endemic than pandemic, I don’t know when we’re going to do this. In my patient population, in the schools now that kids have been sheltered in for so long, we’re seeing even worse pediatric obesity, signs of insulin resistance.
Dr. Ronesh Sinha
So I think, in one case, I don’t want to create a doom and gloom picture, but I also want to create a picture of hope, that there are simple things you can do through lifestyle changes that can reduce your risk of developing these outcomes in the near term. And the good news is, many of my patients that have been putting off lifestyle changes because heart disease seems so remote, now they’re actually willing and accepting the fact that yeah, I understand cytokines, I want to get the visceral fat down, I want to make those changes.
Dr. Ronesh Sinha
And one way I kind of reframe it is, I tell people, you treat COVID-19 sort of like a sporting event. It’s like you’re training for a 5K or a 10K. How do we get you less breathless through physical activity? How do we elevate your VO2 max? How do we get an inch or two off the waistline? These are all goals that I had even before COVID-19, but how do we accelerate those goals? And now that I’m giving talks to schools, I’m really trying to push, how do we really emphasize physical fitness more in the midst of the pandemic, because that’s what all parents are thinking about, is vaccines and pandemic, but is this an opportunity to really hit the hammer a little bit harder on lifestyle changes.
Dr. Mark Hyman:
Absolutely. It’s such one of those moments. I have fear it will pass us by and we’ll miss the chance, but I think it really is important for us to get really serious about it. What are you seeing, related to these sort of A1C and the continuous glucose monitoring in these COVID patients? You sort of touched on it a little bit. Can you talk a little bit more about it?
Dr. Ronesh Sinha
Absolutely. Since I’ve got a lot of techies, these patients like to develop spreadsheets, and they follow their data very closely. So even though I’m not a COVID-19 front liner, I have seen in some of my patients that have had a COVID-19 infection, they shared their continuous glucose monitor data with me, and some of them actually saw early elevations and markers of increased glucose in the early stages of infection. Which isn’t surprising to you and me, but already, they were starting to see the metabolic impact of that. So, I thought the CGM sensors were very powerful from that.
Dr. Ronesh Sinha
But then, the other part that I’m really starting to see is many of my patients that had a COVID-19 infection and cleared it, some of them, their A1Cs unexpectedly went up, despite their lifestyles being the same or even better. Their CGM sort of unexpectedly went up as well, too, even though it was rock stable for several months or even for a year of doing CGM data. And that, to me, was already a marker that, wow, this is doing something that’s a lasting metabolic effect.
Dr. Ronesh Sinha
And you know, someday, Mark, I mean, 5-10 years from now, that might be part of our general history, is did you have a COVID-19 infection, as we’re screening for heart disease risk and diabetes risk, because these infections might be doing some lasting damage that we’re not aware of.
Dr. Ronesh Sinha
Now, this is very anecdotal, from what I’m seeing in just small cases, but I think as we collect data and we look prospectively beyond this pandemic, we have to think about if somebody had a COVID-19 infection, let’s be even more aggressive about checking their baseline numbers. Maybe they get a CGM. Check your labs more regularly to see, is there a trajectory that’s steeper as a result of COVID-19? So, something I think we need to be aware of going forward.
Dr. Mark Hyman:
Amazing. So, how do you help people sort of in the thinking about the most important lifestyle and dietary changes to reverse this? Because you know, it’s not just South Asians that are affected by this. Clearly, they have more predisposition, they have higher risks, and they get it at lower weight, with lower body mass. But like I said earlier, 88% of Americans are metabolically unhealthy. That means they’re insulin resistant to some degree. And what’s striking with COVID was that it wasn’t like, oh, if you’re obese then it’s a problem, but if you’re a little overweight, it’s not a problem. It was a linear risk of hospital admission and death with increasing weight and poor metabolic health. So, it wasn’t like it was a zero risk if you just had a little extra belly fat.
Dr. Mark Hyman:
You really are at risk, and I think it’s important to understand this, that what can you do to deal with COVID? You can take care of yourself. It’s not just about masks or vaccines, or Ivermectin, or whatever people are talking about. It’s about your own wellbeing. And I don’t know, I don’t know why I haven’t had COVID. I’ve been around a lot of people, and I’m careful, but still. I wonder, is it just because I take my vitamins, and I get enough sleep, and I eat well, and I exercise, and I meditate?
Dr. Ronesh Sinha
Oh, absolutely.
Dr. Mark Hyman:
And I just wonder if that’s a part of it. And how do you advise your patients to sort of create a bulwark against COVID through lifestyle?
Dr. Ronesh Sinha
Totally. I mean, I think you’re an example of what I explain as biological versus chronological age. I know we put the number out there, 60-65 and over, 70 and over as being high-risk, but I’ll tell you, I’ve got some patients above age 70, I’m less worried about them than some of my 30-year-olds, just based on their level of fitness, their healthy lifestyle practices. I’m more worried about the outcomes in my 30-year-old patients who are sedentary and already pre-inflamed. I love that term that you used.
Dr. Ronesh Sinha
So, I think this is an understanding we have to understand. You know, obviously we have to use things like age just for population health. These are ways that we can sort of collect data. But we’ve got to really make people aware of these terms, that the amount you can physically be active, not being breathless, what are the elements of the diet and things. And as a healthcare system, we have to infuse this into our practitioner system too, so when physicians again are overwhelmed, they’re obviously taking on so much, but can we refer more patients to dieticians and lifestyle services, consult practices, as part of the COVID-19 strategy, which is just really focused right now on just vaccines, and obviously social distancing.
Dr. Ronesh Sinha
These things are important, but part of that recipe has to be, how do we actually surround these people with lifestyle prevention strategies, so we can again bring down that cumulative cytokine load? What you’re doing through your lifestyle practices, I’m not surprised that you haven’t been infected, because your immune system is naturally so robust, and that’s what we have to teach our patients around this.
Dr. Mark Hyman:
I hope so.
Dr. Ronesh Sinha
Yeah, right.
Dr. Mark Hyman:
Maybe I’ve just been lucky. So, in an average day in your life, because you had metabolic syndrome, how do you stave it off? How do you create great metabolic health for yourself? What’s your routine, breakfast, lunch, dinner, activity, sleep, everything?
Dr. Ronesh Sinha
Yeah. One thing I would say is, I’ve put a lot of emphasis on diet so far, and that’s still a big foundation, but one interesting thing I’ve noticed in my practice, now that I’ve been doing this for a while, is many of my patients, when they lowered their starch and they reversed insulin resistance, they were like, wow, all I need to do is diet? Because a lot of them are adverse to exercise. Culturally, we are a very sedentary species, we South Asians. We like to sit in front of computers and learn a lot, but we don’t like to exercise very much.
Dr. Ronesh Sinha
But the interesting thing is, those patients that reversed it, now they’re coming back to me and they’re like, oh my god, now my A1C’s gotten worse. What’s happening? I’m eating the same diet that I did. And I tell them what we talked about initially, is you’ve undergone mitopenia or sarcopenia, because you’re so sedentary, with age, you’ve lost mitochondrial horsepower, so we’ve got to elevate that physical activity and exercise. I just want to add that in there, because a lot of people feel like diet is the only way to do this.
Dr. Ronesh Sinha
So, in my typical day, starting with that is, first thing I tell a lot of my patients is, many of my patients, and this is kind of a cultural thing, are evening walkers or exercisers. So, they get out of bed, they’ll hop on the computer, they’ll have their breakfast, maybe. Maybe they’ll fast. And then they hop on their computer, and they’re sitting for 10, 12, 14 hours, and then they’ll walk the dog or do a walk with their significant other for like, 30-40 minutes.
Dr. Ronesh Sinha
And I applaud them for doing the walk, but I tell them, if you want to rev up the mitochondrial engine, you’ve got to start in the morning. Like, if you start with some physical activity to get that metabolic car started… a lot of us are not wasting time in cars in commutes. You’ve got to start there, because then, even when you’re sitting in Zoom meetings all day, you are burning more fat and energy. So, that morning is a really key window.
Dr. Ronesh Sinha
And you see with CGMs, when you wear continuous glucose monitors, you get morning exercise, and all of the sudden, your glucose is much more stable, even as your dietary fluctuates.
Dr. Mark Hyman:
All day long.
Dr. Ronesh Sinha
All day long, yeah, right. So, it’s a powerful thing. So, morning, whether you’re fasting or having a light breakfast, get some physical activity in there. And then, throughout the day, you can probably tell right now I’m standing, right? I’m very fidgety, because I’m constantly sitting, standing, moving. I’m in Zoom meetings where I’m doing what I call sort of yoga at work. So I’ve taught a lot of my techies, how do you keep the body moving while you’re actually getting your work done, rather than looking for that magical hour of physical activity at the end of the day or so? And that’s been a very powerful thing. I’ve seen people stabilize their blood sugars just by interrupting prolonged sitting and inactivity.
Dr. Mark Hyman:
Yeah, what do they say, sitting is the new smoking?
Dr. Ronesh Sinha
Exactly right, yeah. So, that’s another key strategy. And you know, that’s, from the stay at home sort of workplace, obviously a lot of us are missing out on going to the offices, but now we can be very creative, right, in terms of how we move throughout the day. You take your dog out at lunchtime. All those little exercise snacks throughout the day can have a powerful impact on that.
Dr. Mark Hyman:
Snackercise?
Dr. Ronesh Sinha
Snackercise, right, exactly. And then, the circadian rhythm is something I brought up. This is a big factor, because again, Asians and Indians tend to eat very late dinners. This is part of their culture, is that they might have dinner around 8:30 or 9 PM-plus. So, just getting… That’s one piece of low-hanging fruit.
Dr. Mark Hyman:
Really?
Dr. Ronesh Sinha
Yeah. Oh, totally. A lot of them will eat very late. I’m like, okay, if you’re not going to make any changes at all, just take that meal, and just pull it back an hour or two. That’s just something powerful we can all do, and that can already lead to pretty significant improvements in the numbers. And then we sort of focus on how do we impact each of those meals. So, circadian rhythm, regular movement throughout the day, those are really low-hanging pieces of fruit that we can use to really have a high impact on metabolics.
Dr. Mark Hyman:
That’s amazing. I think-
Dr. Ronesh Sinha
By the way, you mentioned one other thing is the cardio, right? So, the cardiovascular exercise has to be… You mentioned VO2 max. We talked about that early on. This is a key thing, is many of my patients of all ethnic groups are doing too much high-intensity exercise. Many of them have been doing a lot of bootcamps, they’re doing a lot of Crossfit, and often that doesn’t have the same impact on VO2 max and insulin resistance. So really dialing in that exercise at the right dose, that boosts mitochondria without triggering inflammation, is sort of the magic.
Dr. Ronesh Sinha
And a key approach that I use, I’m a big fan of Phil Maffetone. I actually did a podcast interview with him a while ago, but he’s got a very simple paradigm, where generally you just keep your exercise, 80% of it or more, at 180 minus your age. So, if you’re 40, your target heart rate’s 140. If you’re insulin resistant, you might have to subtract five or 10. But that’s a magical-
Dr. Mark Hyman:
180 minus your age. So, I should be at 120?
Dr. Ronesh Sinha
Right.
Dr. Mark Hyman:
If I’m 60, I should be at 120?
Dr. Ronesh Sinha
You’re 120, but since you’re fit and you’re not insulin resistant, and if you’re a regular exerciser, you might add five or 10 to that. So maybe between 120 and…
Dr. Mark Hyman:
I mean, I went bike riding yesterday, and had my heart rate monitor on, and I got up to 155, and averaging in the 130s, 40.
Dr. Ronesh Sinha
Yeah, that’s the thing. Not necessarily bad. I mean, I can already tell by talking to you that you’re somebody that fitness is a regular part of your life, right? So you might have that foundation to work on. But if you really want to upgrade fat burning and reduce insulin resistance, you’ve got to do a lot of work in that 180 minus age zone. And Maffetone has trained world-class endurance athletes. And it’s literally, you’re trying to build that aerobic base.
Dr. Ronesh Sinha
So, for a lot of my patients, it’s fast walking instead of running. The majority of my patients should not be runners at all. I look at their Apple watch data, and they’re basically 150, 160. And I’ve had a fair number of patients, Mark, develop a heart attack while they’re running or they’re on the treadmill at a high heart rate, because most of their workouts are very inflammatory. They’re burning a lot of glucose. They’re generating a lot of excessive reactive oxygen species in them from their workouts. They’ve got to start with the lower heart rate foundation. As they get fitter, they’ll get faster at that lower heart rate. When you look at elite athletes, they’re less breathless in the fourth quarter of the game because they have such a wide aerobic base.
Dr. Ronesh Sinha
But my patients that don’t want to exercise, they want to do the 20-minute HIIT workout and then get the heck out of there, and I wish that was the case, because I don’t want to work out for that much longer. But you’ve got to put in at least 30-45 minutes of what Peter Attia calls zone two, or I call the Maff heart rate, based on Maffetone. I know it’s not the most exciting exercise, but it’s absolutely fundamental to really reversing a lot of these conditions.
Dr. Mark Hyman:
That’s amazing. Well, you know, Ronesh, your work is really amazing. You’ve really brought to light a lot of challenges that affect specific sectors of our population, and about a third of the people on the entire planet.
Dr. Ronesh Sinha
Right.
Dr. Mark Hyman:
It doesn’t get really talked about enough, and it helps us understand some of these cultural and ethnic disparities. I think the education you do is really fantastic. I mean, you make things digestible, simple and easy. I encourage everybody to go to CulturalHealthSolutions.com, and learn. He’s got a wonderful free COVID survival guide, a Covesity blog explaining it all. I read it. It’s very good. It’s Ronesh Sinha, S-I-N-H-A, MD, and I encourage you to check it out, because quite a robust bunch of information, and it’s fun. There’s a lot of graphics and pictures.
Dr. Mark Hyman:
So, hopefully this conversation woke you up to what is really underneath a lot of the health conditions that are driving our COVID pandemic, our obesity pandemic, and it’s really the world’s, I think one of the biggest problems we’re facing. And it’s no surprise, given our diet and what we’re eating, and the fact that now we see 67% of kids are eating… I’m sorry, 67% of the diet of kids is processed food. So, that’s why we’re in this mess, and it’s only getting worse.
Dr. Mark Hyman:
So, thank you so much, Ronesh, for what you do. For those of you listening, I hope you enjoyed the podcast. Be sure you find me on social media. You can comment. We’d love to hear from you, how you dealt with your “cobesity,” or “diabesity,” or your obesity and diabetes, and subscribe wherever you get your podcasts, and we’ll see you next week on the Doctor’s Farmacy.
Speaker 1:
Hi, everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medicine practitioner, you can visit IFM.org and search their find a practitioner database. It’s important that you have someone in your corner who’s trained, who’s a licensed healthcare practitioner, and can help you make chances, especially when it comes to your health.
