Renowned endocrinologist Dr. Roshani Sanghani believes that the battle against diabetes will be won not with more medication, but less. She joins us from India to discuss her unique approach to combating this global health crisis. Dr. Sanghani's "lifestyle-first "philosophy stresses cultural understanding and patient education over heavily-prescribed medicines. As you'd expect, her approach is making waves, as well as getting extraordinary results.
Is carbohydrate restriction a viable treatment for diabetes or is it merely a controversial theory? Dr. Sanghani challenges conventional guidelines because it often overlooks the role of diet in disease management. We ask her why the medical community resists this therapeutic approach. She touches upon possible reasons, such as conflict of interest and cognitive bias, and emphasizes her call for a more comprehensive, patient-centric approach to treatment.
Finally, Dr. Sanghani shares some good news about her upcoming book on diabetes management, which she hopes will help revolutionize the current approach to diabetes.
-----------------
Connect with Dr. Sanghani
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
Twitter:
Learn more:
Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
Renowned endocrinologist Dr. Roshani Sanghani believes that the battle against diabetes will be won not with more medication, but less. She joins us from India to discuss her unique approach to combating this global health crisis. Dr. Sanghani's "lifestyle-first "philosophy stresses cultural understanding and patient education over heavily-prescribed medicines. As you'd expect, her approach is making waves, as well as getting extraordinary results.
Is carbohydrate restriction a viable treatment for diabetes or is it merely a controversial theory? Dr. Sanghani challenges conventional guidelines because it often overlooks the role of diet in disease management. We ask her why the medical community resists this therapeutic approach. She touches upon possible reasons, such as conflict of interest and cognitive bias, and emphasizes her call for a more comprehensive, patient-centric approach to treatment.
Finally, Dr. Sanghani shares some good news about her upcoming book on diabetes management, which she hopes will help revolutionize the current approach to diabetes.
-----------------
Connect with Dr. Sanghani
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
Twitter:
Learn more:
Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
Welcome back folks. It's the stay off my operating table podcast. Dr Philip Ovedia. I'm your co-host, jack Heald Phil. I think this is a first in a number of ways. Tell us about our guest and let's get this party started.
Dr. Philip Ovadia:Definitely Really excited and honored to have Dr Roshani Sangani joining us from India. So our first guest from India and also our first endocrinologist. Just to set the background for the non-professionals in the audience, which I think is most of our audience endocrinologists are doctors that specialize in hormones and, most commonly, diabetes. Roshani is an amazing endocrinologist who is taking a little bit of a different approach that I'm excited to discuss with her. But before we get into it, why don't you give a little bit of your background to the audience, roshani?
Dr. Roshani Sanghani:Well, thanks, Phil. Thanks for having me on. Jack, it's so good to be here and yes, although I'm logged in from India, I've sort of had an international ride and I'm so lucky about that is. You know, I was born in the States and people ask me about that is you're from India and you don't have the accent and I'm like I actually have two accents, depending on who I'm talking to. And I spent my first 10 years of life in Chicago and then we, my family, moved and as a child, I came to India and spent the next 13 years here in India and finished med school and then, after MBBS what we call med school in India I again took off back to Chicago where I did another 10 years since, which included residency and endocrinology fellowship, some private practice, and then in 2011, we made one more international move back to India. So it's been India since 2011 now and it's been fun so far.
Dr. Philip Ovadia:All right. And so since your return to India, you know you've been in practice in endocrinology and talk to us about sort of what you've seen there. Give us the lay of the land. I think people are very familiar with the metabolic health and diabetes epidemic that we have going on here in the US. What are things like in India?
Dr. Roshani Sanghani:Yes, sadly similar or maybe even worse. You know we hear this sentence a lot, that India is the diabetes capital of the world. You don't hear India as the obesity capital of the world, and there's a reason for that is the Indian body type comes under what we say the South Asian, which is the. There's some reason why we cannot tolerate obesity as well, so we get sicker faster. So if we start gaining weight, if you have a Caucasian person gaining weight, you have a person of Indian origin gaining weight around the waistline, especially around the belly. The Indian person is just genetically and statistically likely to get diabetes or cardiac disease faster. We think you know, yeah, and I've spoken to some experts about this. You know we think that there's some 50 gene. You know you think about India. A large part of India is in a warm place, so we always had food availability. We didn't go through cold stretches where there were snowy, icy winters where we didn't have access to fresh. You know hunting and gathering opportunities, but it was always amply available. So you didn't need to carry around fat for your, for your daily routine. And so maybe now, with this nutritional processed food, you know, tsunami that's hit everybody around the world and we're copying the West. We're doing that. It's we're doing our own sort of fast food hike, high carb, you know transition and so you do see a massive uptick where you know if you do. They've done spot checks and about they've seen numbers like one in three with pre diabetes and India's population recently overtook China. So this is not a good number. It's a huge, huge number.
Dr. Roshani Sanghani:And maybe I'll add a little bit of my backstory. Here is when I moved in 2011,. Coming back, I knew that I had been out of the country as a professional for 10 years, so I didn't want this gap between me and my patient. So in the US the way we practiced was as the endocrinologist, we talked to the patient, we assess them, we write our prescriptions, medications etc. Look at the blood reports, tell them when to come back and then we may say go see the diabetes educator. So a large part of what I focus on in endocrinology is anything to do with hormone imbalance, metabolic or insulin resistance. So diabetes is a big part of that.
Dr. Roshani Sanghani:So we would say go see the educator and then the patient would go with that folder and make an appointment and get some sort of education. And I had no access to what they were talking about. So I was like this works, but I want to sit in on that. I was having some formal is what's the amazing stuff that's happening there with patient education? I should probably arm myself with that, since I'm about to go practice in a foreign country.
Dr. Roshani Sanghani:In a way, even though my roots are Indian, I had never worked in India, so I wanted to know what an educator does so that when I get to India I could do the education myself selfishly, because I would get information from each patient. I would know what the culture is, I would know what their lifestyles, their beliefs, their value systems. I didn't just want to be disconnected from them, telling them what drugs to take and then outsourced to an educator. I needed to first know what what's happening. So no in between between you know how, like cut out the middleman. So I wanted to just directly know from my patients. So that gave me the lay of the land about what's going on in this country and whether it's family styles, cooking styles, beliefs, misunderstandings, myths, phobias. I spent about three years sort of accumulating knowledge on that and then finally started doing, you know, group classes, education and since then the practice. You know there's a story there, but I've just made it a lifestyle first practice.
Dr. Philip Ovadia:Yeah, so talk about that some more the lifestyle first approach versus the pharmaceutical first approach. That, I think, is more common here in the US.
Dr. Roshani Sanghani:Exactly so. One of the beautiful sentences that stayed with me when I took the CDE exam in the states, the certified diabetes educator exam, so that I really knew what it means and the textbook just my job dropped that there was like a penny drop moment, which was, it said, go to the patient empowerment model, not the patient compliance model. And what that means is, you know the word compliance comes from, like government is are you compliant? Are you fire safety compliance? That's where we heard here in this work, but it had inner. It had sort of jumped into the doctor patient relationship where compliance on behalf of the patient was supposed to mean are they taking their medication regularly? Are they doing what you say? And as a doctor, you've sort of worked your way up this sort of professional ladder where you somehow become top, top dog. Right, you're this apparently. I'm not saying we are the smartest people in the room, but the world seems to portray that the doctors are the smartest people in the room because we have so many degrees and we take so many tests. But I think we had some knowledge gaps.
Dr. Roshani Sanghani:So the switch to patient empowerment was very interesting, was like huh, I like this. You know, I have always been fascinated with behavior change and mind body medicine and I was like I like the ring to that. I don't want to be told what to do. I would rather, as a human being, that someone gave me my options, inform me of my choices and then let me decide. It's just a human need and I was like, well, everybody's as human as I am, so why would I not want that for them? I mean, maybe it'll work better, and this sort of state as a notion in the back of my head. Until I had this one specific interaction with the patient and I think he was like my light bulb moment patient, where he was sent to me with heavily uncontrolled diabetes. Hb1c was like above 11% in spite of an normal should be. A non diabetes level of HB1C should be less than 5.7.
Dr. Roshani Sanghani:Thank you so what this means is yeah, thank you, I figured you'd ask me what. How do we make sense of the numbers? Appreciate that, yeah, and if you think a fasting glucose level should be below 100, we're talking about somebody having a 90 day average blood sugar in their bloodstream of about 400.
Jack Heald:I know that's bad.
Dr. Roshani Sanghani:Yeah, it's really bad, right, it's really bad. And he's sitting there talking to me normal, like he's calm, cool, he's stable, he looks like he could go walk out and go and have a meeting and do everything normally. And this is in spite of him being compliant with four different oral diabetes medications and my job. The doctor who sent him to me said but it said it on the referral note non compliant that was like his name, like you know, john Doe, like John, non compliant though it was almost like that's who he is. Yeah, not good, right? And the man says I'm not going to take insulin. And what's the endocrinologist's job? You know, we sort of are in diabetes. We're supposedly you know it's the highest level of training is where the hormone doctors.
Dr. Roshani Sanghani:Diabetes is a hormone imbalance. Insulin is the key hormone we're talking about. So my job was, as per my training, you know, I'm told if you have an HB, one C, above a certain number, like nine, in spite of multiple oral medications, you need to switch this person to insulin. So I tried that conversation and he was like, absolutely not. I've seen people go downhill once they start insulin. Nobody ever got better once they got on insulin. I'm not doing that and I realized I can't make him come. Yeah, good for him, and he's like yeah, good for him.
Dr. Roshani Sanghani:And I'm sitting there stumped is like I'm stuck now what do I do? And I didn't want to get into combat with him. He was in my office. He wasn't there to irritate me or waste my time. He was there for guidance on his health. He could have been in a different location if he wanted to be sick. So I'm the assumption is, this man does not want to be sick. I need to find a way to work with him, and so then that bulbs us went off.
Dr. Roshani Sanghani:About two things went off, you know, I think, thankfully, because of having multiple inputs in my training. I had to go out of my way to get it, but I had. It was patient empowerment was one thing that stayed, and another thing that was as of that time was only in the diabetes education books. It had not come into the American Diabetes Association or the clinical endocrinology guidelines, which was to say that reducing carbohydrate intake can reduce the need for medication and can bring the glucose levels down. This was like some secret sentence that was not front and center for doctors and these ideas just sort of accumulated. Yeah, go ahead.
Dr. Philip Ovadia:No, I was just gonna. Well, first of all, certainly want to hear the end of that story, but also ask why is that? Why is this secret hidden from doctors? And wanted to hear kind of what your perspective is in the endocrinology community at large, both here in the US and in India. Why therapeutic carbohydrate restriction is not a accepted treatment paradigm.
Dr. Roshani Sanghani:I think it's a tragic fact. You know who. So then they're like. Should we talk conspiracy theory? Should we talk conflict of interest? Should we talk cognitive bias? In the doctor's mind Is I know that it's common sense to tell the patient fix your diet, fix your exercise.
Dr. Roshani Sanghani:Type two diabetes is a lifestyle disease and that's the thing that used to bug me. It used to bug me to no end. This paradox is we call it a lifestyle disease and we also sit in conferences saying it's a chronic and progressive disease and like those two things don't add up. You know, the missing link between those two sentences is if the person with diabetes does not change the lifestyle, then it's a chronic and progressive disease. These two things were separated from each other, I don't know by accident or what, and even today you know, if you look for the American Diabetes Association guidelines about therapeutic carbohydrate restriction, it's in the fine print, it's not in the colorful algorithm about how to treat diabetes.
Dr. Roshani Sanghani:And I just picked this algorithm apart with Tony Hampton, who's another SMHP provider in Chicago, and on his podcast he asked me like walk us through what you think needs to be improved in this treatment algorithm for diabetes, and one of the things I said there was. It's a pharmacotherapy, it's about prescription. It has the word on top diet, lifestyle, exercise, weight loss. There's like one line there so that you're not legally not saying it. But the entire algorithm is dedicated to one way traffic of if one medicine fails, at two, at three, at four. If the kidney is damaged, try these meds. If your heart's failing, give these meds. If you have cardiac coronary disease, go for these. And I'm like, wait, that's way too far ahead in the game. And just like you say, stay off my operating table. We're way too late if we're waiting to make prescription decisions based on once somebody's heart is involved with diabetes, or kidney is involved.
Dr. Roshani Sanghani:And the carbohydrate bit is in the same document. Every January they publish this and it's a very quick sentence. It's so hard to understand. You know how they say. You should say things in a way that a 10-year-old should be able to understand this sentence. Let me try. It says in people in whom achieve what? Is it Uncontrolled? Yeah, in people not achieving glycemic targets. First of all, I'm already lost Not achieving glycemic targets means they're going.
Jack Heald:I'm saying something that the endocrinologist is lost.
Dr. Roshani Sanghani:Yeah right, I'm trying to piece this together. Like what do you mean? Say it to me in English that means your glucose is too high, not achieving glycemic targets. Fine, that's the first part. And in whom achieving normal glucose levels with less medication is a priority. Oh my God, say that simply. So here's a person who has uncontrolled diabetes, who would like to have normal glucose levels with less medication right, Like that should be everyone right I think that's everyone.
Dr. Roshani Sanghani:Thank you, you know, I think that's every single person, but that person is not represented on this colorful algorithm. It's in the fine print, which busy doctors probably don't read. The sentence finishes with in those people, a low carb or a very low carb approach is a viable option. Now, there's evidence behind this and they've given you links and all that. But it's so hard to fish it out and run your career like that, run your practice based on that. It's just not easy. So I think doctors are missing.
Dr. Philip Ovadia:It. Just, like I said, the implicit, you know, assumption there is that most people aren't going to want to control their diabetes with less medication, and that's what's really so, you know, sad and shocking about the way that the ADA, you know, phrased that in their guidelines. And, like you said, why isn't that at the top of the algorithm? That should be the default, and then, if that's not working, okay, let's go to some medications.
Dr. Roshani Sanghani:Oh yeah, so many lines would be impacted if we use carbohydrate restriction as the first approach, and I just don't see that happening. In fact, you still have guidelines saying and even in India it's being published like this that carbohydrates should be 55 to 60% of the meal. On what basis? And I've read documents that say you should do that to prevent ketosis. I'm like on what basis? Why? So?
Dr. Roshani Sanghani:This is a bit technical, but just because somebody is using fat for fuel. So if you don't use carbohydrates for fuel, you're going to end up needing to burn fat for fuel. I thought most people don't want the extra body fat. Last I checked right Is nobody wants to be walking around with that extra body fat and yet we're saying so. When you burn fat for fuel, you're going to produce ketones. That's not the same as diabetic ketoacidosis, which is a very rare complication of diabetes. So all ketones are not ketoacidosis and this is like a major educational gap here is nutritional ketosis, or changing somebody's nutrition by reducing carbohydrates so that they burn fat and generate ketones, is actually a healthy, helpful thing. The body was wired to do that and yet you've got guidelines saying put 50 to 60% carbohydrates in the plate to prevent ketosis, and maybe I need to get more famous so I can then rip these guidelines apart and get into more trouble by criticizing them more openly, but this is what we're facing right now.
Jack Heald:Well, I have a hope, yeah, well we definitely need that to happen.
Dr. Philip Ovadia:Maybe go back a little bit, and at what point in your training or career did you kind of come to this realization that we could be instructing patients to reduce their carbohydrates rather than just putting them on more and more medicine?
Dr. Roshani Sanghani:Yeah. So that gentleman that I met in 2013 was the one who sort of gave me my light bulb moment, was multiple ideas sort of came crashing together from theoretical knowledge in my IQ bank into doctor-patient relationship in the room. This man is here for help. He's saying no way am I taking insulin. And I had to come up with some new way of talking to him and connecting with him. And then it just clicked. I was like, oh, let's go through your diet, recall. And it was like guess what? He was eating eight to 10 Indian flatbreads like chapatis they're about six inches, they're like tortillas, wheat. Eight to 10 of those per meal. So we're talking 24, or maybe, if you didn't have so many of them at lunch, let's say 15 to 20 of these tortilla type rotis chapatis per day. So I was like do you think you can reduce that and take more vegetables and more protein instead if you're hungry? Cause he was doing that to satisfy his appetite. He wanted to feel full and because carbohydrates are really not that filling to keep you hungry, and this much knowledge I have, I was like can you reduce that and give more carb, give more protein and vegetables? And he was like okay, I can do that. If you're saying that you won't force insulin on me, I'm gonna do that. And I tweaked his tablets around a bit.
Dr. Roshani Sanghani:I was very nervous Cause this was the first time I was breaking the law. According to me, I was like doing something outside of guidelines. I did not send him out with insulin and I was like worried about him. I was like is he gonna get sick? And he looked fine. He walked out. He came back a week later. His glucose levels had gotten better without me having pushed the insulin on him, just by him cutting his chapati count to half.
Dr. Roshani Sanghani:And in my interview with diet doctor, some people got mad at me. They're like you're not talking about the rice eaters. I've done this again later on with rice eaters. Same thing is when cause India has either roti or rice as the predominant carbohydrate on the plate, and I've seen that when they cut that to half, the glucose levels drop drastically. And so then that became my negotiation tool Every conversation.
Dr. Roshani Sanghani:I was so excited by this finding. I was like wow, this feels better. I just would not wanna be on so much medication myself. If the person's getting better with less medication, there's no problem here. There's no conflict. And he was feeling better. He looked absolutely clinically comfortable. So that's what we did.
Dr. Roshani Sanghani:And you know this other sort of. Again, we were told that if someone's failed on four tablets, that means that their pancreas is dead. It means that they have no more insulin production in the body and that's why you need to give insulin. That was one of the arguments that we were using. And again, you know how sometimes you have data or knowledge in separate buckets in your brain and they don't talk to each other. So in type one diabetes, again, we treat type one diabetes. That's where it's supposed to be the experts for managing that is very minute and precise insulin prescribing. That we do.
Dr. Roshani Sanghani:And one of the ways that we can confirm that this is type one diabetes is by a simple blood test. We do the CPAP type test and we know that this person's pancreas is definitely not making the right amount of insulin, your insulin deficient, and this person needs insulin to survive. But we were never doing that test in the type two population. We were just assuming that a standing, walking, talking, comfortable man with scary high glucose must have a non-working pancreas. Therefore, I must give an insulin. But a person with type one who has a non-working pancreas is extremely sick. They're losing weight, they're getting into hospital, they are getting into ketoacidosis. So it's not the same process. It's medically a totally different thing. So this bulb sort of clip is oh, I don't think his pancreas is dead. I need to work with that working pancreas and work on lifestyle change, and that was like a big turnaround for me at that point in my head.
Jack Heald:So one of the things that I was fascinated by went to your website and I'm sorry I don't remember what it's called, but we'll get that. Make sure that you get to talk about it went to your website and it was how you work in your clinic and you said one of the things it says is we don't do single visits, and I drilled down what's that all about and it really made sense. And then I'm setting the table here because I want you to unfold this approach. And then you've got somebody on your staff who is a spiritual healer. I'm not saying it was right, but it's a combination of we do a program.
Jack Heald:I want you to talk about that, because the way you described it was super cool, and you've also talked about the spiritual I guess that's the best word for it the spiritual side of things, and you have this person on your staff. Maybe those things are related. I don't know, but I've never run into this particular combination of healing modalities and programs and I think it sounds really interesting. I'd love to see something like that adopted here in America, if I understand it. So tell us about it?
Dr. Roshani Sanghani:Sure, yeah, I'd love to thank you for going through that. I would love to talk about that. So here I need to do a bit of a personal journey segue and I think even Phil, you had a sort of personal health awakening that triggered a big transformation in the way you see healthcare, similarly to mine, in the sense that 2011, 2012, when we moved back from the US to India, it was a big personal, professional adjustment. I wouldn't say it was like the happiest two years of my life. It was kind of very, very stressful, lots of adjusting and unexpected situations I had to adapt to and I did not have enough coping tools. So I went through a very big stress patch and my hemoglobin A1c entered into the pre-diabetes range, purely from stress. Purely from stress. My food was the same, my lack of exercise was the same, my sleep and etc. Were the same. The big difference was I was going through chronic, daily, 24-7 internal stress in my head. I just couldn't cope and I really was about to hit bottom.
Dr. Roshani Sanghani:And a friend of mine just she'd been my old friend, I just didn't know that she was a spiritual teacher and if you believe in the universe or you believe that there's something out there looking out for you. I think that was looking out for me. Whether you call it God, or you call it wisdom or consciousness, or just whoever put the sun and moon in the sky, whatever that was, that same thing was looking out for me and I ended up talking to her and she said you're ready to learn some spiritual practices? Now I was at such a wits end I would have done anything. So she said you're ready to learn Reiki? And that's where my brand comes from is Reisan, is the R-E-I of Re? Yeah, reisan, r-e-i.
Jack Heald:My wife is a Reiki practitioner. What do you know? Oh, I know almost nothing, but I know that she's extremely gifted and an extraordinary healer. So I'm not completely ignorant about Reiki. Carry on.
Dr. Roshani Sanghani:Exactly exactly. So that's what entered my life. And she said you're ready for Reiki. And my joke now is, in hindsight, this was 10 years ago. I said you know what, If you had told me that day that you're ready for monkey, I would have done monkey. You said Reiki, so I did Reiki. I was so. I was like fully in surrender mode. I was like tell me what I need to do. And so that's when my spiritual journey started. It changed me as a human being. It changed me as a person with my ability to see emotional pain on the other side of the table.
Dr. Roshani Sanghani:And I think sometimes we get scared of the word spirituality. We think it means religion, we think it means God, and we don't need to make it that complex. For me, spirituality is knowing my self-care, knowing myself, my emotions, my what matters to me, what triggers me. And if I become more and more aware of myself, I'm going to see similar reflections in the people outside. What I think are, you know, they're bringing problems in my life. Actually, we start seeing each other as reflections of each other, and the world would be such a different place, right, If we could all do this. It's very hard, it's extremely hard, but I try, I really do try. I'm not anywhere near Buddhahood. I'm very flawed and very, you know, I can be fragile and crazy sometimes, but it's a journey and because I saw the power of it, I realized that talking to one person one day changing their medicines and sending them off into the wild never knowing if they're going to come back right. So in India especially, it's another awkward situation is outpatient medicine has not driven through insurance. It's out of pocket, self-pay. So if someone meets me in my practice and I change their medicines today, I might think reducing rice or chapatis is great and I'll say do you promise you'll reduce your carbs? Okay, here I'm making all these medicine changes Off. You go See me in two weeks. What if they never come back? I've now set them up for trouble Is. It's not safe. There's no medical supervision, and this actually happened. I had to get burned and learn this.
Dr. Roshani Sanghani:The hard way was I was operating out of the old fashioned acute care model. See, healthcare became an official career track for people, especially once surgeries were invented, antibiotics were invented. Acute medicine became very life saving. But when you're dealing with chronic medicine, it's not like a one time visit. I save your life today. It's got to be long term. It's a life.
Dr. Roshani Sanghani:If we talk lifestyle right and I have a sort of a mantra for this is life is what happens to you every day and lifestyle is how you respond to it every day, it's not just one day. So I figured if I want to have a say in reducing people's medication, I need to be connected with them over a longer period of time so I can go deep with them into their nutrition, their sleep, their stress management, slash spirituality, their exercise, their time restricted eating or intermittent fasting. Especially then can I do justice to walk them through this journey of better health with less medication. So it was on me to upscale myself in all of those verticals.
Dr. Roshani Sanghani:Read like crazy geek out. I'm a professional geek, right, I'm a lifelong geek. I can study and learn, and that's how the program only approach came. And what we've done now is we will do a single consult where we get to know each other, because sometimes it's hard for someone to jump into a three month commitment when they have no idea what you're talking about. They think you're crazy. So we do the one consult where we get to know their backstory. They get to know our philosophy. I won't change the medicines in that meeting. It's more like this is time for us to introduce each other, and then I lay out what's coming if they work with us over three to six months.
Jack Heald:So, if I understand it, what's your? It starts with this model of which bucket of health problem do you fall in? Is this an acute problem or a chronic problem? If it's an acute problem, it's not you. They need to be seeing. I'm not so far, right.
Dr. Roshani Sanghani:Exactly right.
Jack Heald:If it's a chronic problem, then it's not fixed with acute style care. It is addressed through an entirely different model of treatment.
Dr. Roshani Sanghani:Exactly so I had to design that.
Jack Heald:It sounded very complicated, but it sounds actually kind of blindingly obvious. But I don't know that I've ever heard anybody actually say it that way.
Dr. Roshani Sanghani:Yeah, the truth is sometimes always staring at us, in front of us, but we don't see it because we've got all these again cognitive biases on. We've got all the so. For example, if I look at the algorithms right, it says avoid clinical inertia, reassess every three months. That implies that you're seeing the person once every three months. But am I not delusional if I think that just because I write something on a piece of paper today, the human being is going to walk out that door and do this for 90 days? Is that even reality? But we say it so often and then when they don't do it, we say they're non-compliant. And so I have been a bit investigative about this, like I've been sort of sniffing around in the subtext for things.
Dr. Roshani Sanghani:I'll give you another example. There was a document that came out by the EASD and ADA, so the European Association for the Plans of Diabetes or Study of Diabetes it's a European body and the American body and they came out with this document called patient-centered approach. Now that had already started appealing to me. I was like, yeah, let me read this document. I go read the document. And they had another colorful chart, and the colorful chart the old version of it had decision buckets for doctors. Busy doctor has to decide. This person in front of me. How should I treat them from a patient-centered approach? And one of the deciding yes, no.
Jack Heald:I'm going to pause, right, I'm going to pause just a minute as the patient. The concept of there's something other than a patient-centered approach just blows my mind. Why would we have to say that? I would assume, as the patient, you're centered on me. Okay, sorry, exactly, I had to get that out of my mind.
Dr. Philip Ovadia:You're exactly right, jeff. The fact that there has to be a document from these international societies getting doctors to consider it as an option to have a patient-centered approach instead of it being the default, is kind of insane.
Dr. Roshani Sanghani:It's insane. It's insane and that's what I'm telling you. We don't even notice what's going on is we're all going insane. And so I'm, so many thoughts are coming in my head. I'm going to try and stay organized, yes, patient-centered. There's another document that's come out that says language matters. There's a paper. So we need papers like this to remind ourselves. Oh yeah, how I talk to the patient matters, I need to be reminded of that. This is what's happening to the world. So I'll come back to that paper second, but let's come back to this one.
Dr. Roshani Sanghani:So here's these little colorful triangles. So it's like a triangle. It's like a right-angle triangle. So there's got this vertical line, it's got this straight line and then it's got a triangle slope. So on the left side it says you should aim for tighter glucose targets and on the right side it says aim for milder or I would say, less stringent targets. Now the decision tree they've shown you is who should be pushed for a more normal HB1C. So if normal is below 5.7, or if you want to take 7, which is above that, you should be prescribing. Below that you can try lifestyle. Whatever number you take, push for tighter control in the following types of patients.
Dr. Roshani Sanghani:Okay, here's where it gets tricky. One of the top ones over there was it's not in the document anymore. They've taken it out because somebody fought it used to be there. It said patient motivation and expected adherence efforts. If the doctor thinks this person looks like a motivated, a de-rent kind of person, I will work with them on getting their HBO once you're closer to normal. There are so many things wrong with this. What's the way? How do you diagnose? Can you look at people and say that? How do you assess this? What's your measurement tool?
Dr. Philip Ovadia:Yeah, when you say it out loud, we're kind of here laughing about it, but it just sounds so crazy. It's tragic that there would be a bucket of patients who you shouldn't try and control as well. Let them be more sick.
Dr. Roshani Sanghani:Yeah, because they don't care.
Dr. Philip Ovadia:Right. Well, they don't care. Of course. You're well familiar with the trials on more restrictive glucose control versus less restrictive, and the concern always being that if we try and get these patients to normal blood sugar levels, that we could end up harming them by doing that Right. There have been trials that have shown that it's dangerous to tell a type 2 diabetic that their A1C should be normal less than 5.7.
Dr. Roshani Sanghani:I can comment on that. Those were the afford and the advanced trials. They saw worse cardiac outcomes in the groups that were pushed. These papers came out during my fellowship time so we had to tear these apart the accord and the advanced trials. They actually had to stop one of those trials prematurely because too many people were dying in the intensive part where you're pushing the A1C lower and lower. But there's a very big bold print there is they were pushing the HB1C lower and lower through prescriptions, not through lifestyle. If I'm going to push the sugar lower, I'm not giving it to you. Naturally, that's when the deaths were happening. We don't have a trial that shows that lifestyle getting A1C to 5.7 and below versus medicated we don't have that trial. We have the 2002 DPP trial, which is a beautiful study. I can come to that, but I need to finish the story about what happened to this nasty.
Dr. Roshani Sanghani:What do you get to diagnose people's motivation based on their facial expressions or based on their name? I don't know how you do that. It was in there is that's how you can decide. There were other things like age or lots of comorbidities or other things. Then, of course, there was pushback from the. I wish I was in that room when they thought about this to hear what the two sides were saying to each other. I'm sure there was a group of coaches, psychologists, diabetes psychologists, educators, who were saying this is totally, blatantly wrong. You cannot do it this way. What came few years down the road?
Dr. Roshani Sanghani:That chart got modified. Now the way it reads is they show you modifiable patient characteristics not modifiable or potentially modifiable. In potentially modifiable, they've put patient motivation, patient level of adherence. It's a potentially modifiable feature, which means somebody has to intervene and help increase the levels of motivation of this person. That's where this beautiful world of, I think, motivational interviewing comes in, which is another soft skill I got trained in, which is when you see someone not doing what they know is good for them. How do you work with them?
Dr. Roshani Sanghani:Whether you say it's addiction or you say it's eating lots of sugar, when you know you have diabetes. These look like self-harmful behaviors. They're the opposite of self-care. On the surface it looks like, but they have reasons why they're doing it and they're not doing it for suicidal reasons. They're doing it for self-soothing and that's their version of self-care. To sort of drill into that soft space, I've taken a really long road to try and explain to you why we do this in a program only approach. What is the meaning of self-care, how I got to what spirituality means. I've jumped around a bunch of different topics but I hope I'm trying to answer your question.
Jack Heald:This is great. What this says to me, the way you're answering it, is this is a physician who has spent a lot of time thinking about not just the surface problem but the problem that led to the surface problem and the problems that led to the problems that led to the surface problems. You've gone layers down so that you can actually be a healer rather than the retail arm of the pharmaceutical industry.
Dr. Roshani Sanghani:Yes. Thank you for rephrasing. Yeah, you rephrased it, yeah.
Jack Heald:I'm a big fan of healers, not so much a fan of drug salesmen.
Dr. Roshani Sanghani:Yes, we had to rebrand ourselves. Our tagline is where healthcare meets healing, because we think that there's a journey here and we need to meet them somewhere in their journey. They want to heal and they get to define what that looks like for them Healthcare, not sickness care, not illness or disease care, but healthcare. That's why we got in here. We didn't get in here to prescribe them the cheapest drug or to avoid the side effect kind of drug. We were here to help our patients heal. We were not here to avoid getting flagged by insurance companies or making our hospital targets and revenue targets. That's not why we entered healthcare. Yes, healing was the reason we came in.
Jack Heald:I feel like I may have interrupted you and you didn't get to finish your story.
Dr. Roshani Sanghani:I don't remember either.
Jack Heald:You're apologizing for how widely you're setting the context to answer my question about the spiritual side of healing and the programmatic work.
Dr. Roshani Sanghani:Yes, the language matters document. I can come to that. We need a document to remind us that how you talk to the patient matters is are you talking to them with blame? Are you talking to them with you? Should you have to? You need to, you're expected to, you're supposed to? That's coming from the compliance model. In fact, we shouldn't be using the word diabetic. We should say person with diabetes, we shouldn't say alcoholic. It's like you're putting it in their name that you are this person. It's part of your identity. If I'm talking lifestyle change, I'm talking habit change. I'm talking behavior change.
Dr. Roshani Sanghani:I love this book by James Clear. It's called Atomic Habits. It's such a good book. It talks about what's the most long lasting way of changing habits that don't help you or adding habits that would help you. I can give you an example here I'm not too abstract is he describes three rings of change. It's in his book. There's the central, the middle and the outermost ring.
Dr. Roshani Sanghani:Most of us try to change habits based on an outcome we're looking for. So I'm going to go on a diet because I want to lose weight. So the outermost ring is the outcome I'm seeking the result, which is I want weight loss and we usually typically go outside in, which is I want weight loss. So I will change the middle ring, which is process is to get that result. I'm going to change my process by going on a diet. That's the middle ring.
Dr. Roshani Sanghani:The inner ring is who I am, my identity, my values, my beliefs. I am a sweet. I have a sweet tooth. I pray sugar. I am somebody who cannot resist junk food. That's my name, that's my identity.
Dr. Roshani Sanghani:So when you go outside in changing process because of a result driven approach, you hit a dead end or a roadblock or a conflict in terms of sustainability, because now your goals and desires are not matching your self-talk, what you're saying about yourself. It's clashing. So the way to change that is, to go inside out is first examine your identity. Is what do you say about yourself? And we let people say this all the time it's oh, I have a sweet tooth. In India they've taken it one step further. They're like I have 32 sweet teeth. I was like yeah, really Do you want to continue lying like that to yourself? Language matters, so words matter. Words have power. If you speak in a self-limiting way, that says a lot about your beliefs. I am an emotional eater. That's saying that's my identity at the core, and then try putting yourself on a diet when you haven't changed who you are. It's not going to last. So it reminds me Change.
Jack Heald:Well, there's a yeah go ahead. There is a in the book of Proverbs. There's this proverb that says out of the fullness of the heart, the mouth speaks and um it does.
Jack Heald:If you want to know what how you really do perceive yourself because what we're talking about is, if your identity hasn't changed then the outcome you desire is the outcome we desire. Our outcomes are a natural outflow of our identities. So what you're saying is that these words that we speak about ourselves are expressions of our identity, how we perceive ourselves. And until we perceive our own identity differently, we're not going to get long-lasting change in our outcomes, right? Exactly, exactly, exactly, and you're an endocrinologist working with people from this standpoint how awesome is that.
Dr. Roshani Sanghani:I love it. I can't do it any other way anymore. I just can't, and I'm going to stay with the thread you gave me just now. It was so beautiful. Say that again the heart speaks.
Jack Heald:Out of the fullness of the heart, the mouth speaks.
Dr. Roshani Sanghani:That is so beautiful. I love that and that's what I love about truth, right? Truth, when it comes out from a new spot, it's the same truth. It doesn't sound different, it sounds the same. I've never heard that particular truth before, but truth recognizes truth the way you heard it in what I said and you connected the dots and you saw truth right. So let me go more deep. Since you've asked for the spiritual angle of this, right now I'm going to go with that. And since your wife is a Reiki healer and that just happened by accident, right, let's go one step deeper with the emotional eating. Or I have a sweet tooth statement and let me now bring in a spiritual. How can that become spiritual when you say that about?
Dr. Roshani Sanghani:When somebody says that about themselves as a belief or identity, how do they feel? How does that sentence make them feel? Thoughts lead to feelings, lead to actions. If you ask any psychologist who's doing work with you, they'll say thoughts, thought patterns, lead to emotions, lead to actions that become you do that again and again it becomes habits. You do that again and again it either becomes health or disease, right? So, like you said, go one step lower, deeper, deeper, deeper.
Dr. Roshani Sanghani:If I'm saying first principles, what's at the core of all this? So if I say I have a sweet tooth, I can't resist, I'm emotionally weak. People have said sugar is my weakness right, let's use that one. Or French fries are my weakness. What does that thought make me feel about myself? Up or down? Probably down, right Is I can't trust myself, I don't have willpower. I've got that one a lot. I lack willpower. Low self-confidence If I get more deeper with it. Low self-esteem I'm not worth it. Low self-worth. Now we've gone big time into spiritual zone. Yeah, big time. You keep doing that. And then you come to the diabetes doctor and I just give you diabetes medications. Then it's chronic and progressive. We're never going to win like that, and so that's why you know what. That's why I have somebody spiritual who's an actual therapist on my team, because guess what they find they do these things and it goes into inner child work, inner child work.
Dr. Philip Ovadia:And all along the patient thought they were just coming to you to get a prescription right.
Dr. Roshani Sanghani:Yeah.
Dr. Philip Ovadia:I mean, this is one of the services that we have been doing. We have been really imposing on our patients in the traditional healthcare system by telling them that they can't get better. The only option is take more medicine. Take more medicine. It's going to get worse over time. We're going to do our best to manage it and that's basically our approach to chronic disease in the healthcare system. And instead of working with patients to empower them to understand how they can overcome and that's really what gives me such hope about the future is more and more practitioners like yourself, all of the practitioners that I meet now at the meetings that I talk to in all the different arenas who are giving their patients this hope back that they can improve and reverse these diseases.
Dr. Roshani Sanghani:Yeah, and I think education is a huge part here for the healthcare providers because, like SMHP, for example, now has a Society of Metabolic Health Practitioners, now has educational content. They have a network from South Africa. They have educational content because I was not trained in how to use nutrition to heal, sleep management to heal, stress management, to heal, exercise, to heal, fasting, to heal. Five giant treatment buckets were not taught to me. I was only taught the prescribing benefit. And now I know all these things and I'm seeing them work in practice.
Dr. Roshani Sanghani:And every person will take their time. They may invest heavily on the nutrition bucket. Maybe spiritual is not something they need to do right away. They're not ready for it. It's not my decision who needs to go how deep in which bucket. We need to give people the menu of options. We need to give healthcare workers training in all of these options so that they have more tools. Right now, even if a doctor wants to help the patient heal, they don't have the tools. They just will be at a loss is okay. If not medicine, how do I help this person? I don't know. I just don't have the skills.
Jack Heald:Bill comment on that. What went through my head was oh my God, I've never thought about what it must be like to be a physician who's gone through however many gazillion years of training you've been through with the idea that you're going to be able to express your healing desires if you get this education and then be standing in front of a person that needs healing and you just don't know what to do. What's that like?
Dr. Philip Ovadia:Well, I think that's a large contributor to this physician burnout problem that we're seeing.
Dr. Philip Ovadia:I think this is why physicians are getting so frustrated.
Dr. Philip Ovadia:We blame the technology and the administrative burdens and all of that and, yes, those are all issues, but at the core of it, I think every doctor I know their motivation for going into medicine was to help people, to help people get better.
Dr. Philip Ovadia:And when you spend your whole career seeing your patients not getting better, they're just getting worse and you don't know what to do about it. It's very demoralizing and we've had so many physicians on this program at this point who have talked about what it was like when they were able to make that change. And now they can see their patients getting better and you see how enthusiastic Roshaani is about her practice and the people that she works with, because they're getting great results and they're getting better and she's actually helping people, which is what she went into medicine for in the first place. And my experience maybe wasn't as dramatic, because I did get to see patients get better. I did the surgery on them and, yeah, they would get better from the surgery in the short term and I didn't really pay attention to the fact that over the long term. They weren't really getting better, you were operating it.
Jack Heald:It was an acute situation at that point.
Dr. Philip Ovadia:Yeah, it was an acute situation.
Jack Heald:Their acute tools were able to resolve an acute situation. Fair enough.
Dr. Philip Ovadia:Yeah, but yeah. So that's why it is so powerful. And we had Doug on a few weeks ago, doug Reynolds from the Society of Metabolic Health Practitioners and the work that that organization is doing the nutrition network, like you talked about other projects that are underway to really help the practitioners as well as helping the patients.
Jack Heald:Oh man, my brain is spinning. Okay, okay, rashani, what do we do now to infect the rest of medicine with this particular virus that you've contracted and are actually helping people? What do we do? How do we make it happen? Yeah, what are you doing?
Dr. Roshani Sanghani:What can we do to help? Thank you. And now that you've sort of tasted the sweet spot, you want to share it with everybody, right? You want to spread the word, you want to make everybody know about this. So my effort to that is to write a book which will publish in the summer. Actually, phil, you really helped me, so I'm confident now that it's going to come out in the summer of 2024.
Dr. Roshani Sanghani:And it is a book about. The working title is Turn Around IVs and it's a book on lifestyle change. I don't know if that'll be the final title We'll still hash it out but the book is all about lifestyle change to have better diabetes experiences with less medication, whether it's type two or type one. And obviously people need to use that book with their medical doctor supervising what they try to do. It doesn't replace what they should see their health care providers for, but it is meant to be empowering that people can think about their health with real steps, what should they do, step by step. And from that I think I expect there's going to be another book that needs to come out, or a course or something for health care providers to train them so they can do this and I'm 46.
Dr. Roshani Sanghani:I've spent many, many years acquiring all these tools. I don't want another physician to have to spend 15 years each trying to get this knowledge. We need to speed that timeline up and compress it so that do a course, do a book, start, get mentorship from people like Phil and I who are doing this. There is a community of doctors doing this now. We exponentially need to grow this, empower the people, empower the treating doctors, the educators, the nurses, the dieticians, nutritionists, everybody. It can happen in one generation, I think, and so in my head we've got teenagers coming down with type two diabetes. I've got little children at the age of 10 with fatty liver. We've got a major, major problem. So it's only through knowledge. If we're not going to prescribe our way out of this, then we need to educate our way out of this.
Jack Heald:All right. So I hear a comma there. I don't really want to put a period there, phil, yeah.
Dr. Philip Ovadia:I mean, I would just say it's amazing what Roschani is doing. That's why I was so enthused about having her on and we look forward to the book. But in the meantime, if people are interested to work with you, how can they do that?
Dr. Roshani Sanghani:Yes, so I'm now working globally. Telemedicine I have a virtual practice, so I work with people all over India, all over the world. We do the one-time consult. People get to see what we're about, we get to see their entire backstory and see what they're looking for and if it's a match, then we go ahead. We work three to six months together. So I'm available. My website is raceonhealthcom, I'm on LinkedIn, I'm on Instagram, YouTube. You know I try social media as a whole career in itself, trying to make content. So I'm focusing on the book for now. I'm hoping yeah, I'm just hoping the book will start this and really I have a lot of ambition for this book. I want this book to, like you said, infect everybody. There's every household out now. It's like one degree of separation. Everybody knows somebody impacted by diabetes or lifestyle disease or insulin resistance related disease. It's in every home. It's very, very scary. So I think this is the only way out and if we help each other, I think it will be better All right.
Jack Heald:Well, that's raceonhealthcom. We'll make sure that shows up in the show notes and all the other ways to contact you. Roshawni, thank you, seems insufficient. You have filled me with hope that there are, that there's at least a handful of doctors who understand that physical health is intimately intertwined with our soul, our spirit, our experience, and are doing something about it. It never occurred to me. It might be somebody who actually would do that, but thank God, there is All right. Well, I guess we'll put a pin in it for tonight, bill. Any closing words?
Dr. Philip Ovadia:No, just I echo your sentiments and look forward to all the great work, Look forward to the book, certainly, and can't wait to see what the future holds for all of us who have been enlightened I would say all of us practitioners and how that mind virus is spreading to our colleagues.
Jack Heald:That's fantastic.
Dr. Roshani Sanghani:Thank you Phil, thank you Jack for having me on Roshawni.
Jack Heald:keep us up to date on the progress with the book. People want to know about it and will help spread the word.
Dr. Roshani Sanghani:Thank you.
Jack Heald:Thank you so much for Dr Roshawni Sangani, Dr Philip Ovedia on Jack Heald. This has been the stay off my operating table podcast. Thanks for tuning in and we will talk to you next time.