How to Make Disease Disappear with Dr. Rangan Chatterjee [transcript]

Written by Christopher Kelly

April 27, 2018

[0:00:00]

Tommy:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Tommy Wood and today I am joined by Rangan Chatterjee. Hi, Rangan.

Rangan:    Hi, Tommy. Thanks for having me.

Tommy:    Thanks for joining me. Rangan, you and I have known each other for a few years now and I think I frequently said that if I could I would have you as my doctor. That's perfectly demonstrated by your new book which is what you're here to talk about mainly.

    The book was originally published as the 4 Pillar Plan in the UK. It's now being released in the US on May 1st with the title How to Make Disease Disappear, which I believe is also the topic of a Ted Talk you did a couple of years ago. The book is great. I just finished reading it. The tips on how to improve lifestyle are exactly the kind of things that we would recommend and I absolutely love it. I can't wait to talk about that. But first, maybe for people who haven't heard of you or know less about you, you could tell us a bit about yourself and why it is you're doing the stuff that you're doing now.

Rangan:    Thanks, Tommy. I guess, first things first, I'm an MD, a medical doctor, and I've been singing patients now for nearly 17 years. I guess, during that time, my viewpoint on medicine and the way I practice medicine has evolved substantially. I'm sure you'll resonate with some of this Tommy. You finish medical school and you think that you've been given all the tools that you need to get your patients better.

    The first few years, I thought, yeah, that was great. I was working in hospital medicine, seeing a lot of acute problems, doing my MRCP, the physician examination in the UK. I was going to be a specialist. I was just starting to get more and more, I won't say disillusioned, just a little bit frustrated that we were overly focusing on one area.

    I was studying nephrology. I was practicing in a department as a -- I think I was doing a [0:01:46] [Indiscernible] job. It came to me that I didn't necessarily want to spend the rest of my career just seeing one organ of the body. I want to see everything and how different organs interact with each other. That really led me to take the rather unusual step of moving from specialism into training to becoming a GP.

    My dad is a conventional MD. I could tell you he was a bit confused at my decision to move from the hallowed turf of a specialty to general practice. But nonetheless, that's what I did. I loved seeing all different conditions, all different complaints, how they all interacted with each other. Again, a few years in, actually quite early on, I've sort of reflected at the end of my day how many people that I really helped.

    Honestly, I thought it was about 20% of my patients. I thought the other 80% I've done something for them, I've maybe given them a prescription or made a referral or helped them put a sticking plaster on their symptom. But it was deeply unsatisfying for me. That really led me, along with some personal reasons with family ill health, really led me to go and explore a new way of practicing medicine.

    I come to the States a lot. I study a lot of the courses that were put on by the Institute of Functional Medicine. I went to lots of conferences on the microbiome. What really interested me is as I start to learn more about health and the microbiome and the immune system and inflammation I was re-tapping into my immunology degree which I got at medical school. I did an honors degree in immunology.

    I have never ever used any of that immunology in my clinical practice until I started learning about lifestyle and gut health and functional medicine. I thought, wow, all that stuff I learned about in immunology is highly, highly relevant in terms of how I could help my patients. That's how I'd got to where I am today. I guess, this sort of viewpoint that I have was really thrust into the limelight maybe three or four years ago when, as part of that journey, as part of that evolution, I ended up getting a primetime documentary series on BBC One television which is the main channel here in the UK called Doctor in the House where I went to live with and alongside families for about four to six weeks.

    What's really important, Tommy, is that these guys were all sick already. They had already been under GPs. Many of them had already been under their specialists, yet they were really struggling with their health. Either their symptoms had not gone away or they were on ten, 15, 20 different medications. Their symptoms were still not being controlled.

    Really, I feel very lucky as a doctor to have that experience because you pick up things that you would never see in your consultation room even if you had longer with your patients and you would ask them more and more questions. Actually, you saw a lot of the things that never gets said. What was remarkable for me is that whether it was type II diabetes where I helped a lady technically reverse her condition within about 30 days -- It was exactly 30 days.

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    That reversal, in inverted commas, has stayed there for three years. I've not seen that lady for nearly three years now and her blood sugar continues to do well and it's actually even better that when I was working with her. For me, it's not like a TV gimmick, one month, six weeks on television, wow, show this improvement. This is sustainable because what I've done is I've educated, I've empowered these families onto what the necessary ingredients are to actually keep themselves in good health.

    Actually, that's what really goes into the book, Tommy, is my 17 years of experience. I love diving deep into the science. I love reading science papers. But the reality is that if we talk about the Doctor in the House series, whether it's type II diabetes, whether it's fibromyalgia, panic attacks, insomnia, gut problems, IBS, the list goes on, menopausal symptoms, so many of those conditions I managed to either fully get rid off within six weeks or substantially reduced how much they were affecting them.

    There was a lady with panic attacks and in six weeks we've got them down by 70% just from taking a lifestyle approach. I realize that no matter what the problem is, if we look at these focal areas of lifestyle, what I call the four pillars of health, food and movement, which people have been talking about for years, but also I give equal priority to sleep and relaxation.

    I found that no matter what your current state of health is, you're going to get an improvement. If you've already got a disease, this approach will help you feel better and hopefully help you reduce how many medications you need. And in some cases, will help you reverse your condition. If you want to prevent getting sick in the future, it's the same approach. It's these same four pillars that you can focus on to reduce the likelihood of getting sick.

    If you simply are someone who is tired of waking up every day and need sugar and caffeine to keep you going all day, this approach will also help you. And we've spoken on many occasions, Tommy. I love going deep and I love using supplements where necessary with my patients in clinic but I've realized that sometimes we overly focus on those kind of magic little supplements that we think can have such positive effects on multiple pathways in the body and we forget about some of the basics. That's really what my book is about. It's about reminding people, you know what, you got to get these basics right and they help everyone.

Tommy:    Absolutely. I think there's so many parts of what you just said that are going to resonate with different people listening to this right now. So, at the beginning, talking about the medical professional and not feeling satisfied with the amount that you're helping your patients, I know there are certainly some doctors who listen to this or people who know doctors who feel that way and it sounds like doctors in the UK particularly now that your book is out there are trying to use some of these principles in their practice where they can, which is fantastic.

    But equally, there are a lot of people who very well are in tune with their health and do a lot of their own research either as practitioners or as clients themselves, as patients themselves. It's very easy to get focused on the new thing, the new supplement and basically over time I've certainly gone the same way as you which is the basics are the basics for a reason. That's whether you want to improve performance or somebody who wants to either reverse a disease or prevent a disease process from happening in the future. That's what we really need to focus on.

    I think bringing us back to that is super important and equally maybe as we go through the pillars, if you're somebody listening to this and you have a loved one who might benefit from some of these things, maybe this is a podcast that you can send to them and they can hear Rangan talking eloquently about just the simple things that they can change in their life to improve their health.

    We'll go through the pillars one by one. Stress is the first one that comes up in the book. I thought it's really interesting that you mentioned that you used to think that poor diet was the main cause of the diseases that you saw frequently in your patients but you've actually changed your thinking and now you think it's stress that's mainly the issue. What changed your thinking there?

Rangan:    Tommy, if we were having this conversation five years ago, it would be on diet exclusively. I think that reflects my own personal bias. I think all of us as healthcare professionals, as patients, whatever we do, we all have our own personal biases. If we have changed our diets and improved our health, we think that diet, that's the place to start. That's why everyone gets the most results in.

    Again, it will be a recurring theme for me but I listen to my patients. I had learned from my patients. I used to think that diet was everything but I've realized that actually not every patient wants to start there. In fact, I had a patient a few months with mental health issues. I just could not motivate them or inspire them to make the dietary changes that I really believe would certainly help them in some way.

    What ended up happening with this particular patient is that I was trying to find which lever can I turn with him?

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    Because all these four pillars are interconnected. You change one and it becomes easier to change another one because they all kind of flow into one another. This guy was actually okay with getting more physically active. We worked a bit on that, on actionable stress that he could put into his life. As he got more active, he's now sleeping better and that's when he wanted to and found it easy to make dietary changes.

    So, we got there in the end with his diet and that really taught me a lot. I really realized that actually everyone wants to start in a different place. To go back to your question, Tommy, about stress, because stress is something that we talk about so much. It's common parlance now for people to say, "How are you doing?" "Yeah, I'm good but just really, really stressed."

    In the 21st century, that is just the way people are speaking. I don't think until I studied stress, I realized how damaging it can be to every organ in the body and how difficult it can be to make those healthy, let's say, food or physical activity choices when people are chronically stressed. I think that it's reflective of where we are in the 21st century. What I mean by that is many of us are waking up now and the first thing that we do is look at our smartphone.

    That whole emotional noise is starting from the minute we wake up. For many of us, that noise doesn't actually switch off or even go down until we're asleep in the evening. Because often actually that's the last thing we're doing at bed as well. I've seen more and more that actually when I start addressing this with patients a whole variety of different things start to get better.

    For example, I detailed in the book a lady who had Crohn's disease. What is Crohn's disease, inflammatory bowel disease? This is a gut problem. I'd been seeing her for maybe just over a year along with her consultant gastroenterologist. She was getting frustrated with the immunosuppressant drugs that she was on. She wasn't finding it hugely helpful on her symptoms. So, we made some quite significant dietary changes. She was put on some supplements and she started to get better. Her symptoms were getting better.

    Then I hadn't seen her for about, say, about six months I hadn't seen her and she comes in and see me in the clinic. She's really frustrated. We did a questionnaire. I think it was the MSQ to see how well she's actually doing. She was having to use the bathroom maybe 20 times a day. It was really causing a huge negative impact on her quality of life.

    I realized as I was chatting to her that she didn't have enough [0:12:36] [Indiscernible]. She was like a dutiful wife. She did everything for her husband. She was a really caring mother. She was go, go, go the entire time and she did nothing for herself. Nothing. It just came to me in that consultation, I thought, stress can impact many things in the body. We know that stress can actually have a negative impact on your gut. Stress can negatively impact the microbiome.

    There's some studies which is showing that stress maybe causative in creating increase intestinal permeability or leaky gut. And I thought, okay, well, her diet is pretty good. If I apply this four pillar framework and I go, well, actually her diet is pretty well dialed in at the moment. I'm not sure how I can really make that many more improvements here. But I think her stress levels and her cortisol levels are probably through the roof.

    So, I said to her, "Look, I think we need to tackle this side of things." I said to her, "Look, I want you to--" This is going to sound so soft, Tommy, right? This is very high tech science podcast but this really illustrates a point. I said to her, "Look, I want you for 15 minutes a day to do something for yourself. We kind of figure out what that could be."

    For her, it was simple as a 15-minute walk. She diaried it in. This is a lot of tip I gave to her. I said, "Look, let's put it in your schedule just like you do anything else." So, she'd have that schedule, 15 minutes she'd go walking without her phone. We agreed together on fives minute meditation a day because I didn't want to set the bar so high that she wouldn't actually be able to engage. I said, "I want you to do one thing a week that you absolutely love. There's no reason for it. You just love doing."

    Well, she didn't choose at that time. She went away. She came back four weeks later. And when she left that first consultation, Tommy, she was so irritated with me. She said, "Look, is that it? Where are the supplements?" I said, "Look, just hear me out. Give me four weeks. I just really think this is something that I need to prioritize with you and you need to tackle. Why don't you let me worry about the plan for you and you just worry about trying to implement it," which is often what I say to patients who'd been reading a ton of blogs and they're trying to figure out themselves what's going on and they're sort of confusing themselves.

    Anyway, she comes back four weeks later and the activity she had chosen was salsa dancing. Literally, once a week she went to a salsa dancing class. She hadn't done that in years. And she did do every day her 15-minute walk and her five minutes meditation. On her questionnaire, her symptoms had gone down by 50%.

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    Her condition had not gone. I hadn't reversed her Crohn's disease, but it was significantly more manageable for her. I think that's a really important point for people listening to this, is that for all the high tech advances in science, there's something about getting these basics right. I think stress is probably, although sleep comes close, to being possibly the thing that we undervalue the least.

    We'll put all our efforts onto changing our diets. Many people, I'm sure you see, Tommy, as well have got pretty good diets by the time they end up consulting with you or coming to me. Actually, they've read all the blogs and their diets are actually pretty good. Sometimes I kind of figure out that if we make a 5% improvement in your diet, I'm not convinced that's going to translate in huge improvement in your health.

    Whereas if we start and tackle one of the other pillars and make some small changes there, to borrow an American phrase, you're going to get a lot more bang for your buck making those sorts of changes. And so there's countless cases like that in the book. Tommy, I think I've heard quite a lot of these podcasts before and I know testosterone often comes up which is something that I'm seeing a lot of low testosterone.

    But a lot of us are still not recognizing that the body's hormonal balance is very, very finely tuned. So, very simply speaking, you start off with a precursor, LDL cholesterol, moving to pregnenolone, and then there's a fork in the road. That pregnenolone can either come down towards making cortisol or it can move to another, go down another route to sort of make things like testosterone and estrogen.

    When you're not stressed and when you're not inflamed, which is very rare for many of us these days, things work really, really well. But once you start to have chronic stress and you start to divert more resource in your body towards making cortisol, at that fork in the road, there's much less resource available in the body to go down the pathways to make estrogen and to make testosterone.

    So often I find the way that I'm treating low testosterone a lot these days is by addressing stress levels. I'm finding it in a whole variety of different conditions including weight loss, right? Including weight loss, I find addressing stress is absolutely key.

Tommy:    Yeah. That makes perfect sense. In terms of the precursors and the adrenal or hormonal balance, certainly the stress is the diversion of resources but also when you're in that scenario your, whatever it is, the signals, the information, the stress is telling the body that now is not a great time to initiate growth or to start reproducing. There's a response to the environment that means that those hormones are going to be, the pattern is going to change and--

Rangan:    It's an appropriate response.

Tommy:    Absolutely.

Rangan:    If you are being attacked by a lion and you're stressed, you're not going to start to reproduce at that time. Your body's got more urging priorities. The more we study these pathways and we look at them in the context of the 21st century world in which we're living in, a lot of it starts to make sense in a way that frankly I never thought about it, certainly not 17 years ago when I left medical school but I'd say even ten years ago I wasn't aware of this to the same amount.

    I often think back and wonder how many patients I may have misserved unintentionally without knowing this information. But, I guess, that's just life, isn't it? You sort of learn more about your field. Tommy, another thing comes to mind in stress. It's a couple I saw recently. The husband in the couple had type II diabetes and I think he was on a couple of diabetic medications at that time and his wife was menopausal and always struggled with her weight.

    She was really interesting character because she had always jumped from diet to diet and sometimes she got a few changes but it would always plateau. She came in to see me. They came in to see me together. First, I did start with her diet. I thought, okay, fine, he's got type II diabetes. His diet really isn't, I think, the best for their condition. I've never been a huge fan of the term low carb. I do use diets that would actually come under the low carb umbrella.

    The reason I steered away from using that term is because I do think that we have unfairly demonized fats for 30, 40 years. I think we potentially can start making the same stake with carbohydrates. I know that may be controversial to some. I do use diets that would fit that criteria. I just don't tend to use that term. It's just a personal thing.

    I put them on a diet that was really low in refined and processed carbohydrates. Particularly it was orientated around his type II diabetes. Now, what was interesting for me is that he started dropping weight for fun. Quite literally week after week you could just see it off his waist. His belt notches were going down. He was delighted and we see this so often on this kind of diets. People can respond very, very quickly.

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    But interestingly enough, his wife wasn't budging at all. As much as she loves the husband, since she was delighted that he was losing weight, she was getting pretty frustrated that actually it was the classic this diet doesn't work for me, none of the diets worked for me. And I said to her, "What if it isn't your diet?" She was really confused by this. I said, "Well, what if it's something else that's driving your weight gain or that's there that is an obstacle to you losing weight?"

    With this lady, I did actually do a saliva cortisol on her. It's something I don't do that much anymore. Actually, I used to do it a lot more three or four years ago. I go a lot more on my clinical impression now than I used to. But I did actually do it with her. I was telling her that I thought she was overly stressed and that I think this is a problem and that increase levels of cortisol for long period of time can lead you to hold onto weights. She didn't believe me.

    I thought, okay. She's one of these patients who actually may need the test to prove it to her. We did it. I think her morning cortisol, I think the upper limit of normal -- I think it was a Genova test. I think the upper limit of normal on that test is about 27 or 28. Hers came back at 52, her morning one, almost double the upper limit of normal.

    When she saw it, I remember what she said. She said, "Dr. Chatterjee, I really am stressed, aren't I?" I said, "Yeah, I really think you are." And for her, she needed to see that evidence before she took it seriously that she could be stressed. But again, what did I do with her? It was five minutes of meditation a day. That was all because that's what I bartered and negotiated with her that she could commit to in the consultation. It was 15 minutes every night before bed of just switching off and either having a bath or listening to some music, just having that wind down. And I also did give her a magnesium, actually.

    It was incredible for me. She was very active as well, I've got to say. I think she was going to the gym twice a week and she was walking lots every day. I didn't think physical activity was necessarily the problem. It was just incredible. Four weeks later, she had lost over a stone. The only change that she had made was addressing her stress.

    Just to be clear, she was on a good diet as well. I'm not saying it was the stress and not the diet. But I think that's a really interesting point for people. Weight loss is something so many of us are looking for these days. I love this four pillar approach because you can actually start to apply it on yourself but you can also apply it with patients and figure out actually is there one pillar that I'm really , really neglecting and could I actually get some benefit by tackling it?

Tommy:    Yeah, absolutely. You've kind of covered most of the recommendations that you regularly use in terms of managing stress for people but I was just wondering if there's anything else that you recommended to people and then also your thoughts on whether we can really reduce -- Because stress is subjective thing. It's how we respond to stressors. So, are we reducing our stress or are we improving our tolerance to the things that might cause us stress? Are we improving our resiliency or are you getting people to do both?

Rangan:    Tommy, I think a lot about this question at the moment because, you're right, it is such a personal thing. Something that is stressful to one man may be completely relaxing and not bother somebody else. Is it stressor or is it our interpretation of that stressor? I think it's a bit of both really. I think I'm leaning more towards thinking it's our interpretation of it.

    Actually, if I'm honest, look, my approach is very personalized to that individual in front of me. That's actually the hardest thing I found about writing a book is how do you write a book for the general population when you believe in a personalized approach? We did try to make the recommendations as broad as possible that can then be personalized by the individual reading the book and certainly the feedback I've had certainly in the UK around the country is that's I think I've just about managed to do that so people do feel that they can personalize this into their own lives.

    I find my job as an MD more and more these days is the job of a counselor. The reason I say that is really related to that question you posed me, Tommy, which is a few years ago I was really into measuring cortisol and seeing how I could bring it back down into the so-called normal range. More and more I've realized that actually modern life is busy. It's not necessarily about -- Sometimes it's about reframing that person's approach to a situation.

    I find particularly in my private consultation where I'm spending an hour or an hour and a half with patients, I find I'm spending a lot of my time almost taking on a counseling role and talk to them about how they might look at the same situation a different way. I talk about gratitude in the book. I think the third chapter in the relaxed pillar is on gratitude.

[0:25:04]

    That's some of the science on gratitude, something that I probably would have thought was really soft about ten years ago. I think some of this is pretty good actually and some of it is pretty remarkable in terms of what it does to us and how long those effects can last for. I remember I met the strength coach Charles Poliquin in Manchester a few years ago. I went out for dinner with him.

    Charles is someone actually who I remember as a medical student or certainly as junior doctor. I remember reading some of those blogs and got to thinking why don't I know some of this? Some of this sounds like they could really help some of my patients, the way he was talking about nutrition and insulin and strength training, all kinds of stuff. I know not everyone agrees with everything that Charles stands for but certainly I found that a lot of his teachings very inspiring as a young doctor.

    We went out for dinner and he was telling me about this game that he plays with his daughter every day. It's really a game of gratitude and that he basically would ask his daughter, "What have you done today to make somebody else happy? What has somebody else done today to make you happy? What have you learned today?"

    What's interesting about that is that I thought this would be great for my kids. So, we started playing it at home, my wife, myself, my kids. Although I started off thinking it would be really good for the kids it's not bad for the adults as well, I could tell you. It's just incredible what that does. You spend five minutes over the dinner table with other people playing that and your whole demeanor, your body language, your mood, the way that you're feeling changes so, so quickly when we start reflecting on the positive that's happening in the day.

    I'm not a psychologist, Tommy, although sometimes I wish now I studied psychology in greater detail because I find that it's these little toxics in the world in which we live in today where I see people who are incredibly stressed and incredibly overworked, it's these little strategies that I find make a huge difference with my patients in a way that I never would have considered five or ten years ago.

Tommy:    It's amazing. That's very similar to I think some of the experiences we have in terms of recommend something and the client or the patient is almost disbelieving of the benefit that it could happen. It's really nice to hear such great examples of that actually working in real life because I think those will resonate with people.

    Just before we move away from the stress pillar which I'm glad we've really focused on because I think there's been some great stuff that's come up but you talked about the importance of social isolation, the dangers of social isolation. This is something that we actually talked about both myself in talks and on the podcast before. It's something that's easy to spot and not necessarily easy to fix.

    So, I was wondering if you had any tips there. You obviously can't have a patient come in and you say, "Well, you're socially isolated. What I really need you to do is go and make some friends." Because that's obviously quite difficult to do. How do you approach that in your patients?

Rangan:    That's a great point about social isolation. The wider point there is that these four pillars could easily had been seven or eight or nine pillars. I tried to cover a little bit on social isolation within the relaxation pillar. I did that on purpose because one of the beautiful things about the low carb message, even though I don't tend to use that term that much, is that it's very simple to understand.

    So, using a four pillar framework, I felt that it was easy to get this idea across if I stopped at four. Whereas if I made it seven or eight or nine, suddenly it starts to get really confusing and the idea can't really take off. I sort of try to shoehorn things like connection and social isolation within my relax pillar. One of the recommendations I made there is called reclaim your dining table.

    Now, this isn't relevant for everyone because not everyone lives with someone else. But let me just tell you what I discovered, Tommy, when I filmed the two seasons of Doctor in the House. This is me and this is relevant to your question. I go into a whole variety of different families, a whole variety of different socioeconomic classes around the country.

    What I saw more and more is that the majority of families did not eat together. The very first family I ever filmed with in 2015, I remember seeing -- This is a family of four. Now, we talk about social isolation and we often think about people who live by themselves or elderly or people who don't have access to friends and the community. But these people live together.

    On the first day, I actually said to them, "Guys, what would you typically eat?" The dad turns to the family and said, "Hey, guys, you just want the usual today?" They said, "Yeah, just usual, please, Dad." And so he says, "Come on, Doc. Come with me." So, I get in the car with him and we drive 15 minutes out to town, we get to a drive through McDonald's, he goes through the McDonald's, he orders -- It costs £46 for four people. That's what? $65 to $70, something like that, just for four people. They all had multiple meals.

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    That's a separate story which we can cover. But then what was interesting, we came back to the house and he would dish up and bizarrely enough in the kitchen, they actually had McDonald's trays there. It was like having the premium takeaway experience of actually having a McDonald's but not actually being in the actual café or the restaurant.

    So, we dished it out to the family. What was really interesting was that none of them talked to each other whilst eating. They were all in four corners of the house, two of them were on the sofa, one was watching telly, the other, I think, the daughter was actually on her phone at the same time and texting and being on Facebook. I think the son was sitting on the dining table by himself.

    What was really interesting to me is that's social isolation, Tommy, because they're having their eating, they're doing something that for donkey's years we've been doing together with people in our communities. We would eat together. They were not eating together. One of the recommendations I made to them apart from changing their diet was, "Guys, can you once a day, would you be up for eating around the dining table together? I appreciate if some of you [0:31:02] [Indiscernible] when you're here eating around the table."

    I can't tell you the difference that made. They would report back to me and said, "I got to know my family better. I was finding out my wife's day a lot more than I was in the past." And then they got closer and more intimacy and all these kind of things happen as a downstream consequence of having a bit of protected time together. That's why I make that recommendation.

    Eat one meal a day at the table in company, if possible, without your devices. That's the strategy I'm using more and more. That's something I only got to see, Tommy, by going and staying with families around the country and I got the same feedback everywhere. When families or when a couple or even a single parent with their child, if they made an effort to sit around a table once a day and eat together, they started to connect more. They felt more warm feelings to their family members.

    It had so many knock on benefits, something I'm really incredibly passionate about. Clearly, if I have an elderly patients who lives by herself and doesn't have family nearby or friends, it's a lot more challenging. I'm always talking to them about hobbies. Is there something, is there some class that they could join? But I also say, could you even diary in once or twice a week with your child who lives maybe 200 miles away or in different country, can you diary in a phone call?

    A phone call is not the same as being there face to face. I would argue it's much better than electronic communication which I think is -- Electronic communication, I think, can be quite impersonal, just sending emails to people. We feel that we're connecting but I think we're missing something. And so these are some of the tips I use.

Tommy:    Those are great tips. Reclaiming the dinner table is something that I'm a big fan of. We're busy in our household, obviously, pretty much all the time but we always try to have a meal together at least in the evening and I think that does make a big difference. I definitely recommend that.

Rangan:    I reckon only 30 years ago that was the norm. Every household in the UK, every household in the US, I reckon people did that.

Tommy:    Yeah, absolutely.

Rangan:    We've knocked all these things down to make room for big widescreen televisions, basically. It's amazing how quickly things have changed.

Tommy:    Yeah, absolutely. I think a lot of these approaches end up just being part of trying to rewind some of the environmental factors even if it is just 30 years, maybe longer than that in some cases but that can be enough to have a huge effect. We should probably move on to the next pillar. We can sort of briefly go over. You sort of mentioned some aspects of food and I think that's important.

    Certainly, we would agree that we're in the process of demonizing a different macronutrient now and actually people are moving on to protein now as the next macronutrient that's causing issues and I would certainly agree with your approach more than most of those others. If we talk about improving food quality, again, most listeners, this will probably have a great idea what a good diet looks like.

    If they're maybe going to recommend this podcast to somebody else or want to give tips to somebody else should they be interested in it, what's your approach then to improving food quality? I've really been interested in the setting of maybe people who aren't so well off. That's one of the things that's often aimed at various dietary approaches be that Paleo or low carb or whatever, is that that's all very well and good for you if you're middle class and you make plenty of money but what if you're not?

    What if you are on some kind of benefits or for whatever reason you don't have access to the best quality food or you can't afford it? How will you approach it in that case? Because I think that's probably the majority of people, was a large number of people in the US and elsewhere where that would be the case?

Rangan:    You bring up such an important point which is that these families from the lowest stage of economic classes and groups have such worse health outcomes than the rest of us. It's really hard to stomach really. I've worked in many of those communities. For so many years I worked in a place called Oldham which is just north of Manchester, very right in the center.

[0:35:03]

    I've dealt with a lot of these families who were on benefits. A lot of them weren't working, were struggling to make ends meet. I realized very quickly there that I could spend 20, 25 minutes with them and give them the full outline of really good dietary practices, they may be going into a food environment where they were finding it very, very difficult to make those healthy food choices.

    It really struck home for me when I one day -- I would usually prepare my lunch and bring it with me. One of those days where I didn't get time or I'd forgotten it or something, I thought [0:35:38] [Indiscernible] and buy something. I walked outside that practice and I went I would say a one-mile radius there was nothing, nothing healthy that you could buy. I passed about seven or eight fried chicken kebob and fry shops and there was some was some very, very attractive offers in the window, £1.49, about $2.25, something like that for a huge family meal or something.

    Really incredible stuff that if you are on a tight budget that's going to be quite appealing for you to feed you and your family. So, I absolutely recognize that this is a problem. I mean, look, the principles, again, it's nothing that high tech. The principles that I talk about are minimally processed food as much as possible. That's kind of the -- When you look at all the populations around the world who are doing well, you got to accept that most of them are having minimally processed food.

    Most of them are having local food in season and they are still having treats but just having them now and again. Maybe at Christmas, maybe at Easter, maybe every couple of weekends. They're not having them every day. I remember in Oldham, one strategy I used, because we had a huge type II diabetic population, I started to teach them how to read food labels and I showed them all of various different names for sugar that existed and how the breakfast cereals that they were starting the day with often were just loaded with sugar and were highly processed.

    They said, "What can I eat?" I said, "Well, look, first of all, we've been programmed into thinking that that is the way we must start our day." I said, often these families were actually having quite a large cooked meal in the evening. So, a simple tip was just can you make more of that, put it in the refrigerator overnight and heat it up in the morning?

    Now, not everyone was up for that. There were quite a few families that said, "Oh, yeah, that's quite interesting. Why do I have to have cereal?" And often they would be having warmed up dinner in the morning. That was one tip that I use with them. I find eggs can be an incredibly cost effective way of getting people to eat healthily. These guys were saying, "What was I going to have?" I said, "You can have a couple of eggs at breakfast. It's not that expensive from the local supermarkets or grocery store."

    I find a lot of those, Tommy, said, "Oh, yeah. I didn't know eggs are okay to eat." That's a whole other conversation, Tommy. Certainly, I felt for that population eggs were a very simple and cheap way that they could actually eat some nutritious, in inverted commas, real food. I would say just encourage them to go and look at those vegetables. I'm a huge fan of this whole eat a rainbow concept. Can you eat as many different colors of the rainbow a day as possible? I prefer to focus on vegetables. I'm not anti fruits but I just find that most of my patients, when we talk about fruits and vegs, it all gets lumped up together.

    They're all tending to have a super sweet fruits rather than the vegetables. So, there's a rainbow chart that I use to draw out for them that they use to eat and found that they could a lot of cheap vegetables in the supermarket and not the exotic ones that get shipped in, the blueberries in the middle of the British winter that we're getting from wherever, Spain or Kenya or wherever it's coming from, but actually just a lot of good colorful vegs.

    Sweet potatoes, certainly here in the UK is a very cheap food. I think it's a very healthy nourishing food for our physical health. It's very nourishing for our gut microbiome. It's a cellular carb, but I know, I'm pretty sure you're a fan of Ian Spreadbury's work, which I think is just fantastic. I think sweet potatoes.

    Again, once you start actually going into how much some of these foods are costing particularly if you can actually prepare them really quickly, I find families get on board very, very quickly. I often relate them to things that I do at home. I'm away a lot. I'm busy with work with many people. If my wife's away and I'm at home with the kids, I want to be multitasking while I'm cooking.

    I want to be like playing with the kids in the garden whilst something's cooking. I will just chop those sweet potatoes in, shove things like leeks and garlic, basically I just try and get as much of this prebiotic fiber in as much possible. These things are really, really cheap, just shove them in with some coconut oil or some olive oil in the oven for 20 minutes and then I'll probably just panfry a couple of lamb chops, whatever. I just try and be really inventive around what they already like and actually show them that it's not as much as they think it is.

    If you think about that family I discussed a minute ago whereas that they spent $65 or so on one meal for a family of four, if you compare that to how much it is to buy whole foods, actually the comparison is pretty straightforward.

[0:40:13]

    I do agree for some families that can be incredibly hard but when you just stick to some basics, some colorful fruits and vegetables, things like sweet potatoes, eggs, maybe you can't afford the most expensive cuts of meats or wild salmon, let's say, but you know what, fatty fish, incredibly good for our wellbeing, incredibly good for our brain health. You could get glass jars or tins of anchovies in the UK for about 50p. That's what? I'm guessing, is that what, $0.70, something like that?

Tommy:    Yeah.

Rangan:    That is not expensive, right?

Tommy:    Absolutely. I think that's a good point particularly if you're spending that vast amount of money on fast food. I mean, you could feed a family of four for fractions of that just by buying some vegetables and, like you said, even economical cuts of meat or fish. But one question that I have that sort of stems out from there is: Are you coming up against people who just don't know how to cook, where that art is lost? Or are people in the communities you work with still cooking an evening meal? Are they still able to do that?

Rangan:    Over my career, I've worked with quite a few different practices and those particular practices in Oldham actually the younger generation I notice did not know how to cook but actually a lot of them still live with their parents and their parents were at least in the evening cooking a fresh sort of home cooked meal. But I have worked in practices before with patients who actually genuinely don't know how to cook.

    I mean, I think that's almost like the elephant in the room sometimes that we don't talk about. We're talking about food but if the people don't know what to do with that food when they bring it home then we've got a bit of a problem. I think that is a huge issue. Over the last few months I've got to know Jamie Oliver pretty well and his team and they'd been trying for a number of years to try and raise awareness of this.

    We were just chatting. I was relaying my experience of [0:42:07] [Indiscernible] clinician, at the sort of things I'm seeing and it's something that I think is well recognized that we have lost the skill of cooking. It's just a fundamental life skill that we couldn't have survived if we didn't have that skill. We just wouldn't be here. But we can outsource our foods to all these corporations now and we have done that but it's clearly come at a cost.

Tommy:    Yeah. My question apparently stems from the work of Jamie Oliver who I've been a big fan of since I was 15 or 16 or something. He's certainly been highlighting the issue and it's a huge one. I have lots of questions that I wrote down about all the various different parts of food and diet that we could talk about but that's something that we have exhausted on the podcast a number of times before. So, I would like to move on.

    But before that, there's just like one last section of the eat pillar where you talk about how we're overfed and under nourished. We're kind of in a state now with farming methods, intensive agriculture, the worsening quality of soil. It's difficult to figure out like the micronutrient status of our food. Are you regularly recommending some kind of supplementation in terms of just like the basic vitamin or something or is that for most people something you never quite get to because the rest of the pillars do most of the job?

Rangan:    Great question. Again, my viewpoint on this is constantly evolving. As I talk to more patients, as I read more science, I'm constantly changing my view on this. But where I currently sit on this is in my book I do not mention supplementation. I do use supplementation in clinical practice, not with everyone but with patients where I deem that it's going to be helpful.

    

    The reason I didn't do that in the book is because I think it's very important that we understand how powerful small changes to our lifestyle can be. In fact, I often say that if we consciously make changes to our lifestyle, we unconsciously change our biology whether it's food and food changing the expression of our genes, changing hormone levels, whether it's movement, which can increase levels of BDNF, it can change levels of inflammation in the body, it can change the cytokine milieu in the body, sleep deprivation.

    We could go into all of that but the point is that the changes that we get from our lifestyle are profound. We don't have drugs really that actually can change our cellular biology often in the same way that lifestyle can do. That's why I'm really keen to prioritize these four key areas. I think these are the four key areas that not only have the most impacts on our health but I think we actually exert quite high degree of control over them.

    I think going into environmental pollutants in the book because for many of us there's not a huge amount we can do about some of that depending on where we live. I felt that these four areas are things that we can actually proactively make changes in our lives very quickly ourselves. The supplements I see myself using quite a bit these days, I think magnesium is something that are seeming deficient quite a lot and I see quite a lot of improvements when people take magnesium.

[0:45:04]

    Even when we talk about the relax pillar, I find that people who are highly stressed, magnesium or it's often called the relaxation mineral. it's actually incredibly helpful to help people switch off or just to relax them and to help them get off to sleep. That's what I'm using quite a lot. I see a lot of patients with fibromyalgia and ME and I'm finding that there's a product Advanced Physicians Formula with NT factor.

    NT Factor, I think, is allergy research group and they've got phospholipids for the mitochondrial membranes. I'm finding that incredibly useful. I do the four pillars definitely with those patients but often find they need a kick for a good couple of months with mitochondrial support so I often use phospholipids, I often use CoQ10 and the form I'm using at the moment is MitoQ which comes from New Zealand which I'm seeing some really, really good studies on.

    Yeah, I do use supplementation as well. I don't have a standard multivit but I put everyone on. I think when I first started training in functional medicine a few years back or certainly learning about that approach, a lot of people I was speaking to says, "Everyone needs to be on a multivitamin." I think I've evolved in somewhat in terms that I try to be more specific as to actually what does this person in front of me actually need rather than just give them a general multi. I'm not against that approach. It's just currently I'm not really using that.

Tommy:    Okay. Thanks for delving into some of that. I know some people would be interested. But equally, don't focus on just the supplements and think that you can then get away with not looking at the other stuff.

Rangan:    Again, this is why I learn from my patients. In my clinic, if you came in to see me and you have this kind of bilateral fibromyalgia pains, I may go down the mitochondrial supplement route in my clinic. That's what I possibly do. Literally, four weeks ago, whilst I was coming back from London on a train, I was not good. I was like the irony of promoting a health book is that you wreck your health in the process.

    I was feeling a bit sorry for myself on the train coming back. I was, god, how much longer can I keep doing this? I just want to get home and have a few days at home. And I got to the station. I texted my wife. She didn't respond. I thought she was probably asleep. The kids would be asleep. I stopped off at the supermarket on the way back to actually grab some food, some nibbles to have when I got in.

    I walked into the supermarket and there were these sweet people talking. They put their bags down and one of them was like, "Oh my god." I didn't know these people and they said, "Oh my god, Dr. Chatterjee, we'd just been talking about your book." I said, "Okay. All right, guys, do you like it?" "It's completely changed my life." This lady comes up to me and she said, "Look," I think she did a little video to Instagram straight away about it. It was just incredible. She just said to me, "Look, I've had ME and fibromyalgia for ten years. I only sleep for three hours a night. I have to give up going to the gym. I spent all my savings on private treatments, none of which has worked, and I got your book six weeks ago, I'm applying all the principles, and I haven't felt this good in ten years. I'm sleeping eight hours a night. I've got energy. I've been to the gym four times this week."

    Her husband came up to me and gave me a big hug and said, "Look, I just want to thank you." That gave me such energy and inspiration at that time. And that also taught me, Tommy, that had I seen her in clinic, I would probably have supplemented her. And maybe I will if I do see her in clinic. But the point is, just by applying these lifestyle principles and this four-pillar framework, she was very quickly able to improve the way that she felt.

    Actually, we talked about mitochondria, actually you make the changes that I'm advising or I'm recommending in the book, you will improve your mitochondrial function. It's not just that supplementation does that. These lifestyle changes are that powerful. I just wanted to share that because it's really important that we remember that these things are the basis and for many people that's all they need to get going.

Tommy:    Absolutely. It's important that you keep coming back to that. I guess, speaking of mitochondria, that's a nice segue into the move section of the book. I think the one thing that I'd like to talk about and which you do mention and focus on is sarcopenia, so the loss of muscle strength, muscle size, muscle function as people get older which is a huge risk factor for all cause mortality as well as metabolic disease.

    I just wanted to talk about how you start to approach people getting stronger. I know you have like a five-minute kitchen workout in the book with sort of ten to 15 reps of various exercises. That's all kind of nicely detailed in there. I'd like to go back to when we were in Iceland and I was hosting the Icelandic Health Symposium and you came to talk.

    One of the other speakers was Doug McGuff who's also very interested in this, in sarcopenia particularly and improving people's muscle strength and muscle health. When he's talking about how he approached it, he tells people they need to do super slow exercises or isometrics, holding contractions for long periods of time. Basically, you need to fatigue the type one muscle fiber, activate the type two muscle fibers which is the ones you lose as you get older.

[0:50:03]

    I just wonder your thoughts on how intensely people need to be exercising in order to try and get some of that strength back particularly as they get older.

Rangan:    That conference in Iceland was fantastic. I remember actually Doug did a real time demonstration with me on stage, I believe, with his belt, if you remember.

Tommy:    Yeah, I do.

Rangan:    Which was really, really intense actually. First of all, we need to accept that there's a problem in society, that we have undervalued strength training. I think that's a starting point of this. Now, my job is over 17 years I want to do stuff that works with real life patients that I see. That is where a lot of my recommendations come from. What kind of actually helps the layman on the street who comes into my practice?

    A few years ago, I remember, I was reading about sarcopenia, I was reading about strength training and muscle. I thought, okay, it's really, really important. Arguably strength training might be more important for my elderly patients than my younger patients. And so I would start to go through this with some of them and they'd come back a few weeks later and I'd say, "Hey, guys, how are you getting on? Do you want to get to the gym? It's really important, maybe 30, 40 minutes three times a week."

    Often they'd come back and say, "Doc, I just don't manage to. I'm too busy. I don't have -- The gym is not on the way from my home to my house," et cetera, et cetera. As a doctor, I never thought, okay, they're not doing what I'm saying. I thought, okay, I need to think of a way to make it more relevant and more practical to them in their everyday life.

    You mentioned this five-minute kitchen workout and it sounds like a bit of a joke but it really isn't. It's probably one of the favorite things people get from this book and it was borne out of this frustration of making these recommendations to people and them not doing it. And so I thought, okay, I'm wanting them to prioritize their lean muscle mass. How can I do that?

    With a patient who was in with me, I took my jacket off and I literally got on the phone, "Okay, let's figure out a quick and easy body weight workout now that you can do in your kitchen." For me, when you start asking people to do five minutes twice a week, and I appreciate a lot of your listeners may actually, Tommy, be going to the gym or hardcore but if they've got any friends or family or parents who are struggling I think this is a really great way to start strength training.

    I've got patients who it's simple stuff like press ups and lunges and tricep dips and simple things that people don't need equipment for, they don't need to get changed, they don't need to actually make exercise a big thing if they don't want it to. I've got like a couple in their 60s. I did tell this in the book, Tommy. In their 60s, they were really resistant to strength training. "You know, it's not really for us." and I really thought it would benefit them.

    I taught them this five-minute kitchen workout in the clinic. They were highly, highly skeptical. They said okay. I said, "All I'm asking for is five minutes twice a week." They came back four weeks later. I said, "How are you guys getting on?" They said, "Oh my god, Doc Chatterjee, we love this. We're now doing it for at least ten minutes six nights a week while we run our evening bath."

    The point I'm trying to make is for that particular couple who thought strength training wasn't for them and associated strength training with people in their 20s trying to look buff, by making it simple and accessible for them and putting it in a context that they understood, they started to doing it and now they're doing it more and more.

    Personally, I don't have the expertise that Doug McGuff has in terms of exercise physiology. I don't use the same approach Doug uses although I would if I have a bit more time to actually learn and study that. I think I probably would because it sounds like a very time efficient way to actually fatigue the muscle fibers. But the approach I take is I always start, as I said with those meditations things early on in the relax pillar, I always start with what can that person realistically do and what do they feel motivated and inspired to do?

    Because I find that when you start that and they meet that target, they feel really good about themselves. That increases their motivation to do more. I've got many patients who started off with this five-minute kitchen workout and are now working out four times a week doing strength training in the gym. That's where my approach stems from. How can I actually make a recommendation that actually happens in real life?

    Not just in my book, not just in the science journals but actually in real life with those patients. That's kind of the approach I take. Does that sort of answer what you were getting at?

Tommy:    Yeah. That's the perfect answer. It's important to point out that this is the entry point. This is like a lowest common denominator. What can everybody do? Actually, the way you describe that is similar to the way Doug McGuff would talk about how once people start to gain some strength or some fitness just by starting to do something they want to do more of it and they want to use it and do other activities.

    Maybe somebody starts just by doing five minutes in their kitchen but then actually they'd feel good enough to start playing tennis again or something like that. People want to use what they've got and then get more of it. So, that entry point in making sure that it's accessible to everybody is super important.

[0:55:05]

Rangan:    Tommy, you were talking about the population and food who potentially can't afford all this -- I was in California two weeks ago doing some interviews around this book release. You could eat such gorgeous healthy food everywhere you go in California. It's not cheap. It's really, really expensive and you think actually this is great but it's only accessible to people who got certain income level.

    If you use that same pattern of thinking and apply it to movements, strength training potentially also got that surrounding it which is, "I can't afford a gym, I can't afford a personal trainer, I can't afford the gear that I need to actually wear to look good in those gyms because everyone else got the latest gym gear, right?"

    Again, I'm very proud that out of all the 20 chapters in this book and each chapter is a suggestion, 18 or 19 of them are completely free. There is no barrier. I did that on purpose. I really wanted this to be as relevant to a CEO of a top company to somebody who's a single mother on benefits. I wanted these interventions to be where possible as relevant to everyone because I think every single person has the right to good quality health information.

    The only thing you could argue with, I think, and one of my recommendations which is unprocess your diet, you could argue as, and then we try to discuss a little bit around that, is can someone on the low end can do that in the modern world? I do accept that, that can be challenging. But the other 18 or 19 recommendations are free of change.

Tommy:    Yeah. That's super important. That's something that I'm incredibly passionate about too. That's why I really enjoyed the book and the tips you have in it. Just before we move away from the move pillar, something that really piqued my interest, and I think it will be actually very relevant to everybody listening to this podcast is a section on sleepy glutes and back pain. So, maybe you could tell us a bit about that.

Rangan:    It's my final year at medical school at Edinburgh. I had never thought about my back before like most of us. If you've never had back pain you just take your back for granted and do everything the way you do it. I was helping my flat mate move into our flat for our final year and I was moving her boxes up all afternoon with pulling lifting technique that you can imagine.

    After about three hours something just went and like I literally screamed in agony on the street, my lower right back. I dropped her boxes and I just laid down on the floor in agony. That really started off a ten-year at least process of trying to get to the root cause and get rid of this back pain. What was really interesting for me is that I did probably what people do around their general health.

    You go to a doctor, you try and get the referral. I went to see physios. That wasn't working. I went to see a spinal surgeon that did a scan on my back and there was a prolapsed disc but then I got told that actually -- I think I was 26 when I had the scan. He said, "But if we go and take 100 people off the streets in their 20s and do MRI scans on them a load of them are going to have prolapsed disc but not all of them are going to have pain."

    Okay, great. So, I've got prolapsed disc but that may not be the cause of my pain. Look, at the time, I would say I was a conventional medical doctor. I had all my existing training. But going down that route, taking the painkillers, I saw a chiropractor, a physio, I tried everything. Everyone kept saying nothing would work or I might get short term relief and then pain would return very, very quickly.

    At that time I was trying -- I had to give up all the sports that I love. I was a competitive squash player. I had to stop playing and that really, really killed me. I was searching the net. I was looking for things and I'm very passionate about skiing. I came across this guy called Gary Ward and I genuinely think that Gary Ward is one of the most revolutionary thinkers in terms of movement mechanics that I've come across. He is, I think, really turning a lot of existing rules on their heads.

    I went to train with Gary. He's got some courses. At that time it was called Anatomy in Motion. I thought, wow, Gary is looking at the human body and the mechanics in the same way that I look sort of biochemical pathways in the body. He is trying to get over the root cause of the problem. I don't want to oversimplify Gary's work but very, very simplistically as part of the training, you do body work on yourself.

    My right foot was completely flat, Tommy. For years, I've gone to see a podiatrist who'd given me an insole to give me that arch back. Again, I'm oversimplifying Gary's work, but very simplistically, he said, "Look, your right foot is stuck in pronation. Because it's stuck in pronation, you're not be able to activate and fire your right glute muscles.

    This is not actually a back problem. Your back is taking the strain of these mechanics that aren't working particularly well." That really, really resonated with me because that's how I look at the human body, what's going on, what's the root cause of this problem? Gary gave me two or three exercises with my right foot.

[1:00:00]

    I could feel immediately how my back would just ease off. I'm not kidding you, Tommy, literally it's by doing those exercises that within months I was back playing squash. I'm 6'6.5". I'm a tall guy and I have no qualms about going playing a competitive game of squash, getting down in the corners because I feel that actually my back is rock solid now and a lot of my friends from that time just cannot believe that I'm going back playing squash and moving beds around the house but I know that I've got to the root cause of it and essentially it's through my right foot and my right glutes.

    If you look in my right foot now, Tommy, I've got an arch without an insole. So, actually, just by working on it, I've now re-taught my foot the optimal position to be in and some of those exercises that not only have helped me but I've used those in my ten minute GP consultations with some of my patients and got profound very quick benefits.

    We made a series of videos. We've walked people through these exercises in the book and it's something that's getting a lot of traction because this is something that I see a lot of. [1:01:07] [Indiscernible] has not necessarily going to be the panacea for everybody's back pain but I challenge anyone to do these exercises cause very small exercises. He puts your -- One of them is called flex on a step. What's really interesting about is that he puts your body in such a position where you've gotten no option but to activate your glute.

    Sometimes you can do exercises that should be glute activating but actually you can do them wrong, where you actually go do them but your glutes has not fired. And these ones actually are really fantastic and I encourage people to check them out. Maybe we could link to some of those videos that I've made. If people don't want to get the book I actually made some videos on YouTube so people can actually see how to do them. I'd be very happy for people to take a look and try them out on their own lives.

Tommy:    That's great. We'll very gladly link to those videos. I'd also be interested to hear about the other foot exercises that you did because when I was 12 I fractured basically four metatarsals in my foot and since then my right foot has been -- It's just not quite the same shape. I know also that in the gym my right glutes gets very lazy so I work pretty hard to sort of keep it going. I wonder if sort of in a slightly similar scenario, so I'd be very interested to see those. For exercise maybe you can send me those.

Rangan:    Yeah, I will do. And I would say, Tommy, I would certainly, if Gary [1:02:25] [Indiscernible] get in touch, I could certainly connect you because I think you'd be very interested in his philosophy and what he has to say in this area. I think he'd probably be a really guest for you, actually.

Tommy:    Sounds fabulous. I'd love to have that. I think after your introduction I'm sure people will be really interested to listen to him. Yeah, let's definitely get that done. I'm excited about that. The final pillar is sleep and we're kind of gone well over an hour now but maybe we could just briefly touch on that before we wrap up. Maybe you can give us some of the most important things that you think are affecting people's sleep particularly ones that they're maybe not paying attention to, your clients and patients and then beyond, and how you might sort of help people build a new nighttime routine around those things.

Rangan:    Yeah, Tommy. We chat for quite a while now so in the interest of keeping your podcast the length I'll shorten this. The top line here is that there's no doubt we're living in a sleep deprivation epidemic. That sounds incredibly alarming. I'm not saying that to scare people. I'm saying that because I genuinely believe it's true. I think when we understand what sleep does to every sort of system in our body, the impact it has, I think we very soon start to prioritize it in the same way that many of us prioritize our food.

    You were at Oxford. I'm pretty sure there was a scientist from Oxford University just I think three years ago came out in public and said that actually we're sleeping one to two hours less as a society than we were 60 years ago. The context of an eight-hour sleep cycle, we might have lost up to 25% of our sleep. One thing I'm incredibly passionate about is when we talk about type II diabetes, the common narrative on social media and the wellness world now is all about carbs.

    Don't get me wrong. I absolutely recognize that refined and processed carbs are hugely problematic for some people, if not all people, with type II diabetes. But we often miss out the other pillars. I've got countless case studies of people who actually came in and actually restricting that carbs even further was not the issue. It was their sleep and it was their stress.

    Because actually, sleep deprivation, chronic stress, these things also drive insulin resistance. So many times the narrative is always about carbs. That's just a little bug that I want to get out. Do you think about sleep deprivation even if you're talking about your weight or even if you're looking at type II diabetes? But the interesting point for me, Tommy, in my years of practice is that although primary sleep disorders do exist I'm convinced that in the majority of cases where people are struggling with their sleep or wish to improve their sleep health I think people are unconsciously doing something in their everyday lifestyle that is negatively impacting their ability to sleep in the evening.

[1:05:09]

    So, you mentioned your nighttime routine. Before we go into that, Tommy, I think it's really important the way -- Our sleeping is not just to do with our nighttime routine. We have evolved to have quite a big differential between our minimum light exposure and our maximum light exposure.

    One of the first chapters in the sleep pillar is called embrace morning light. I'm really passionate that we undervalue how important light or a lack of light can be for our overall biology. I don't know how many of your listeners are familiar with this but the unit of light is lux. A dark room, ideally you mean a dark room at night with zero lux although very few of us are these days.

    If you go outside on a sunny day for about 20 to 30 minutes you're probably being exposed to about 30,000 lux. You're going outside on a cloudy day is probably going to be 10,000 15,000 lux, something like that. The last studies I looked at for a brightly lit indoor office in the 21st century, you're looking at about 500 or 600 lux. If you think about that, we have this huge differential and many of us are going particularly in the winter months, we're going from zero or five or ten lux in our bedroom only up to 500 lux in our office.

    So, simply getting outside in the morning for 20 to 30 minutes can have a profound impact on your ability to sleep in the evening and some of the tweets I've had from people since this book came out in the UK is that, "Hey, Dr. Chatterjee, the only thing I did was actually go outside in the morning. I made a concerted effort to go out for half an hour each morning and I'm sleeping better in the evening."

    I think that's a really counterintuitive tip for people to take home. Get outside in the morning. Caffeine is an obvious one. I talk about enjoying your caffeine because I love caffeine as well. I say enjoy your caffeine before noon. It's amazing how many people will say to me, "Doc, I've had [1:06:59] [Indiscernible] cup my whole life and I have in the evening. It's never bothered me. It's not that."

    And this concept that underpins the whole book is this idea of threshold. We all got a personal threshold. Our bodies can deal with multiple insults up to a point. For example, you could be born in optimal health and you could maybe tolerate a poor diet, being sleep deprived, maybe some bullying at school. Bit by bit, you're getting closer and closer to that threshold. Often you don't have symptoms until you cross that threshold.

    Then something will happen like you lose your job or you have a breakup with your girlfriend and then suddenly you get sick, you got all these symptoms and you think it was the last thing that caused it. But actually, it was all these things building up for years that have finally tipped you over your threshold and you have to actually start rebuilding from scratch.

    The relevance of that to caffeine is maybe someone in their 20s when they were nice and chilled and relaxed, didn't have loads of stresses in their life, they tolerated caffeine. It didn't bother them. But actually, as they're getting a bit older and they've got more pressure and mortgage and children and whatever else they got going on, actually maybe caffeine is not suiting them anymore. It is uncanny how many times simply just cutting your caffeine intake down to the morning, and ideally you want to cut it out for seven days and just give it a try and see if it is affecting your sleep. It's amazing how many times these things do affect your sleep.

    I was chatting to Matthew Walker recently. He's a sleep researcher at the University of Berkeley. He was saying to me that for some people after midday -- If you have a coffee at midday, 25% of that coffee could still be in your brain at midnight. So, we wouldn't go to the bed at night. Well, many of us won't go to bed at night and have a quarter cup of coffee just before we go to bed.

    Yet actually, some of us may be having the same effect by delaying our coffee intake. So, caffeine is something really -- If you don't think it affects you, just cut it down and see. Alcoholism is another one, a huge sleep disruptor. We know now that alcohol although, yes, we think it sends us to sleep and it relaxes us but actually, really what it's doing is sedating us. Sedation is not necessarily the same as deep restorative sleep.

    As I say it's often these things that we're doing in the daytime that is negatively impacting our ability to sleep. We spoke about light, bright light in the morning, trying to keep things as dark as possible in the evening. My favorite recommendation is probably the no tech 90. The idea can you, 90 minutes before bed, switch off all modern tech? And I'm particularly talking about smartphones, e-readers, iPads, things like that.

    Twofold reason there. The first reason is the blue light. We know that in nature you tend to get blue lights in the morning or certainly latest in the early afternoon. Yet when we look into these devices in the evening, we're actually giving our body these signals that actually it's daytime, it's sunlight, we should be waking up. But it's not just blue lights. It's also the fact that we are continuing that emotional stimulation coming into our brain.

[1:10:03]

    Actually, one of the commonest reasons why people can't sleep is they just can't switch off. Tommy, what we were talking about before we got on air today? When we were students and we got exams, often we don't sleep the night before an exam because we're stressed out with the things that we'd been cramming again over and over in our minds and we can't switch off.

    And so for people who've got children you know that you don't wind them up before bed. You don't put bright lights on, give them high sugar snacks, put on a really, really exciting cartoon for them to really get them worked up. We read them a quiet story and we have a dim light on and we talk softly and it's often it's just getting these basics in place that actually help us sleep.

    I was doing something on national television recently called the Sleep Revolution over in March. It's incredibly how many people are doing work emails until just before they go to bed. Somehow we think that we can just switch off from that and suddenly wind down. So, there's plenty of sleep tips in the book but that's just a sort of brief overview of some of the tips that I'm quite passionate about.

Tommy:    That's perfect and lots of things that resonate with me recently. The light thing is huge and, yeah, that's certainly something we mentioned to all of our clients as well is that you actually sort of protect yourself from the negative effects of light in the evening by getting bright light during the day. That's probably at least as important if not more important.

    The caffeine thing, I was exactly like that person. I was like I've had caffeine all my life. I'm fine with it. But actually recently I sort of made sure that my caffeine, I'd only drink it before midday and actually pretty much every coffee I have now is maximum half caffeinated so reduced my caffeine intake by more than 50%. It's definitely made a big difference to my sleep even though I was sure that I was fine.

    So, that's all really important stuff. Like I said, I have more than three pages of questions of things I wanted to ask you, I wanted to talk to you about, but we're just not going to have time to cover all of them. This has been an awesome summary of all your best knowledge really and how people should really approach the basics to improve their health and lifestyle and thoroughly encourage people to buy the book.

    You kindly sent me a copy but I bought one anyway. I look forward to that arriving. Maybe you can tell people where to get it, where to find you. I'm sure people will be very interested in doing that. All those different options would be great.

Rangan:    Okay. Sure, Tommy. Thanks very much. The book has been out in the UK for three months. It's called the 4 Pillar Plan. It's about to be released in the US and Canada under the title How to Make Disease Disappear. You can get that from all the usual outlets, from Amazon, Barnes and Noble. If you want more resources on the book, you can go to drchatterjee.com/book. It's all there. You can see a lot of these videos there as well that I'd been talking about for free.

    If you want to reach out to me, I'm on social media. Facebook and Instagram, it's @drchatterjee and Twitter is @drchatterjeeUK. Yeah, I'd love to hear from you guys.

Tommy:    Awesome. Thanks again, Rangan. I thoroughly encourage everybody to read the book, buy the book, buy it for somebody else and share this podcast to somebody else who might need it. I think there's a huge amount of really great information in here. Thanks again for your time.

Rangan:    Thanks, Tommy.

[1:13:17]    End of Audio

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