Introducing: Dr. Roshani Sanghani
Dr. Eric Westman: I have a chance to review and talk to movers and shakers who I think are movers and shakers in the low-carb and obesity diabetes world. It’s my great pleasure to be speaking to Dr. Sanghani. Dr. Roshani Sanghani has a new book on reversing diabetes, Turn Around Diabetes, which we’ll talk about. Welcome!
Dr. Roshani Sanghani: Thank you for having me, Dr. Westman. It’s so great to connect with you. I’ve been reading and learning from your work for a decade at least.
Dr. Eric Westman: Sometimes, we plant seeds, and sometimes they grow. Most of the time they don’t, so I’m glad that you learned it.
Why don’t we start from square one? For someone who doesn’t know who you are, please tell us about yourself.
Dr. Sanghani’s Background
Dr. Roshani Sanghani: I’m an endocrinologist. I’m a hormone and diabetes and metabolism specialist, medical doctor. I did my med school in Mumbai, India, and I’ve lived about half my life in the US and half here, which is why I can flip accents. Sometimes I sound like I’m only from India, and sometimes I sound like I’m only from the US. But my med school was in Mumbai, and then I came to Chicago where I did internal medicine. I was a chief resident, and then I was a fellow in endocrinology. I chose to specialize in diabetes and hormone disorders, particularly around weight and metabolism.
I had to break away slowly from the mainstream the way I was taught. I guess the way I was trained to be a doctor started to deviate away from what I thought I was doing when I entered healthcare, to when I decided to pursue medicine as a career. Over the years, I’ve created a lifestyle-first practice where I don’t want to be the one who keeps prescribing more and more medications without getting into people’s lifestyles. Now I have the great pleasure in working with them over 3 to 6 months on all the habits: nutrition, sleep, stress management, exercise, intermittent fasting – all to help the hormones do their thing and naturally help people achieve the best health they can with the least amount of medication.
Dr. Eric Westman: I think we think in the same way in that regard. My experience was that two of my patients did it in front of me, and I was just curious. How could this happen? They didn’t even need a doctor, god forbid. They used food, they read books about food. What program were you in in Chicago?
Dr. Roshani Sanghani: I was at UIC for my fellowship, and my residency and chief residency were at Cook County downtown.
Dr. Eric Westman: Okay, wow. I have a friend and a colleague at Rush, and there are several other “keto-friendly” doctors in the Chicago-land area. I gave a talk at the Chicago Obesity Summit. They have an Illinois Obesity Society at the state level, and I met a bunch of doctors from that area, including I had a great chance to talk to and hear a talk by Bob Kushner, who is probably the leading drug treatment researcher for obesity and diabetes. It’s interesting how it’s so siloed.
Let’s just take a moment about your training. You mentioned breaking from the mainstream. What are endocrinologists? Internal Medicine doctors can do a subspecialty in endocrinology – what is the training that you received, and how should we treat diabetes?
Dr. Roshani Sanghani: Endocrinology is a word that not too many people have heard about. They all know what a cardiologist is, so I say the same way you need to study beyond your MD in internal medicine to become a cardiologist, where you’re taking another 2 or 3 years extra, the same way for me in endocrinology, rather than specializing in the heart, I took another two years after internal medicine to specialize in the hormones. Not everybody realizes that diabetes is actually a hormone problem. We think of it as a glucose problem, but it’s actually a hormone problem, which is why it becomes a very big chunk of our specialty.
We are sometimes considered the last resort when it comes to diabetes. When it gets really unmanageable at the primary care or family doctor level, it might get bumped up to a higher level trained doctor, and then we might be the last stop in terms of the highest medical training for treating tougher cases of diabetes, or more difficult cases of diabetes.
Unfortunately, what that meant usually was escalating the pills and then eventually getting people onto insulin, and then finally managing the insulin prescriptions because insulin is a hormone, and that’s our field. Endocrinology is the field of hormones. My training essentially was about how and when to add more medication. I did not attend a single course during fellowship where I was taught how to bring medications down. That just was not part of my training.
Shifts in Endocrinology Treatment for Diabetes
Dr. Eric Westman: That’s fascinating. That’s the same for me. In the last century, we were all trained to add more medication. I have a little bit of hope that mainstream endocrinologists will eventually get to the root causes of obesity because they will hopefully transition away from insulin as the glucose control agent to the other shots that are being used for diabetes – GLP-1, the GIP. In the obesity world, we call them first-generation anti-obesity medicines, second-generation, and they’re going to be third-generation. Is there any hope that in mainstream endocrinology, they’ll gravitate toward those medicines? Because insulin really just locks you into diabetes, doesn’t it?
Dr. Roshani Sanghani: Yes, exactly. You’re right. Definitely, we now think about when you’re not doing well on tablets, we think about injectable medication. And within injectable medication, insulin would not be the first thing we would think about. Now, the first thing we would think about would be the GLP-1 analogs, which the most famous one right now is semaglutide, which commonly we call Ozempic or Wegovy. You also have the other injectables like a tirzepitide like Mounjaro. These would definitely be the first-line injectables that you would think about after somebody’s not doing well on just pills.
Diet and Weight Loss Shots
Dr. Eric Westman: Let’s say the mainstream medical endocrinology folks just talk about the shots that lower the weight, people don’t have to be so concerned about what they eat, do they? Or do they? It’s a trick question!
Dr. Roshani Sanghani: It’s a tough question, Dr. Westman, and it’s so highly contested and so highly debated, and it gets very sensitive sometimes, and I know why. If I could maybe walk through some reasons that I think this happens and it’s so contentious. The idea is not to deny people care, the idea is not to deny people treatment, to say you should change your diet first and only if you fail lifestyle interventions should you be offered a drug. That kind of framing sometimes sounds like there’s a judgment or blame going on. That’s where it gets really critical and it gets difficult, and that’s not what we’re trying to do. Healthcare providers are not in practice for that.
Still, I have my own practice stance on this, but just to put more opinions on the table, I hear colleagues who will say, “Well, we’re endocrinologists and we have to be the ones prescribing the GLP-1s because we’re the most qualified to do so. So when new medications enter the market, we need to be the ones showing the way.” I have to listen to that, and I’m like, “But I didn’t take my oath or enter medical school to help more medications enter the pipeline.” I mean, if that was the case, I should have gone into clinical pharmacology research, like, helping new drugs enter into the market. That was not the role I decided for myself. I wanted to be the one who helps my patient heal, achieve better health. If the body is healthier, I think it can be possible with less medication. So this is a philosophical issue.
Another contentious point is when I hear colleagues say – these are smart doctors with good intentions – but they will feel that lifestyle change does not work if the person is severely obese, or lifestyle change does not work if the BMI is above a certain number, or they’ll make certain buckets where it’s not going to work.
Dr. Eric Westman: That really is prejudging, isn’t it?
Dr. Roshani Sanghani: It’s prejudiced and I understand it could be biased. There could be so many things. I know that right from 2013, I had problems with some of the guidelines that were called “patient-centered care.” When you look at the algorithms, it said, “Motivated patient, give more attention to the glucose targets, like bring their HbA1c, which is their diabetes three-month average test, give it more attention to bring it closer to normal.” If the patient is motivated, versus if they’re less motivated, you can relax your glucose targets.
Dr. Eric Westman: If you just tell people how easy it can be by eating a low-carb diet, they become motivated when they realize they can have the food they thought they couldn’t have. Right?
Dr. Roshani Sanghani: And I was worried. I was like, “There’s no blood test for motivation. How am I going to make the right decision here?”
Dr. Eric Westman: When I have a student or a resident with me – I’m at Duke University – I’ll say, “Predict for me if this person’s going to be successful or not,” and we’ll talk about it. I’ll end by saying, “I don’t know. People can fool me and not do it or fool me and do it. But if they do it, you know, I’ll say, you have no doubt that if you do this, it will work.” It’s as with the confidence of using a drug. We have a lifestyle tool.
Still today, I get feedback from endocrine professors when I give a talk about there’s five grams of glucose in the entire bloodstream. If you multiply out with middle school math, the 100 milligrams per deciliter and the professors will say, “You know, I never thought of it that way. That an apple could raise blood glucose.” We now enter in the continuous glucose monitor (CGM) and other methods of glucose measurement. We really don’t need the doctor much or the other doctors.
One last thought there was – doctors used a low-carb diet for diabetes a hundred years ago when there were no drugs at all. When I even bring that up in a medical meeting, they’re like, “Wow, that’s news to me.”
How did you fall out of the tree of the medical mainstream?
Dr. Sanghani Moving Away from the Mainstream
Dr. Roshani Sanghani: Like you just mentioned, the history of using low-carb goes back a century. Insulin only entered our toolkit in 1922. So it’s been only 102 years that we had this life-saving treatment for people with type 1 diabetes. In Gary Taubes’s book, called Rethinking Diabetes helps you look at that entire historical timeline of what was diabetes centuries ago versus now. And yes, the low-carb wave tried to raise its head up anti-mainstream multiple times in history. I’m hoping that now, with the way awareness is going, with all of us getting together, hopefully this time we get it to stick.
How did I fall out of the tree? In your case, you had patients who came to you with the success story of, “We did this on our own,” and it got you thinking, “What was that about?” A scientific mind will be, “Well, how did that happen? You were an exception. You didn’t do it the way I was expecting, and it still gave a good result,” so the scientific mind kicks in. For me, it happened in a slightly different way.
I was still giving mainstream advice to people until about 2013, where pills would fail, and I would say, “You know what, you need insulin for diabetes.” This one gentleman in 2013 said, “I won’t take insulin. I won’t go on insulin. I will do whatever it takes, but I won’t go on insulin.” He told me that in his life he had never seen anyone get better once they started on insulin. It didn’t make them better; nobody came out of illness – they just kept going downhill. I had to listen to him.
Luckily, by good grace or good luck, or whatever it was, I had, before moving from the United States from Chicago back to Mumbai in 2011, along with being an endocrinologist already practicing, I went ahead and took the diabetes educator course. I wanted to be an educator also because I was coming to a new country. Even though India was my country, I’d been out for a decade, so I wanted to be in the education space to really get my ear on the ground to know what’s happening now a decade later in diabetes.
I had to flip from my endocrine hat to my educator hat, saying, “Well, I know about carbohydrates, and he’s saying he’s willing to do anything, he’s not accepting my insulin prescription. Let me talk to him about carbohydrates.” I said, “Are you willing to do this? It might help your glucose come down.” I was a bit dumbfounded. I wasn’t expecting this to be powerful, but I had no other option. I think his pancreas had burned out, that’s what I’d been taught. His pancreas was probably burned out already, so I wasn’t too hopeful. I was actually nervous. But he was motivated, and he came back.
I called him soon, and I didn’t wait too long. The following week, his glucose numbers had dropped. I was like, “How is this possible? He’s still eating carbohydrates, and his glucose is coming down? That means his pancreas is working!”
Dr. Eric Westman: The pancreas is working by inference if the blood glucose isn’t going up to 500, 600, 700, 800 (mg/dL). And yet, the American Diabetes Association and the straight mainstream folks are saying it’s a relative lack of insulin, which is totally bogus.
I’m glad you mentioned Gary’s book. Gary Taubes wrote the book Rethinking Diabetes that came out in January of this year, and your book came out this year as well, which we’ll get to. The idea that insulin treatment was in practice for type 1s and type 2s, and it was only late into the game that they were able to measure insulin in the blood, and the insulin in the blood was already high in those with type 2 diabetes. If you go back to the beginning of endocrinology, if the hormone’s high, you lower the hormone; if the hormone’s low, you give the hormone. It makes no sense to give more insulin when the insulin’s already high. But it came in so late. In fact, that seminal article that was written is just a must-read for those in endocrinology training because it says if insulin’s high, lower the insulin level. They say, “Lower it by lowering the carbs and the diet.” Keep going with this case because it made a big difference.
Dr. Roshani Sanghani: It made a big difference. If you’ve ever been exposed to Indian food, this man was eating 8 to 10 rotis or chapatis per day. These are like Indian flatbreads – they’re kind of like tortillas or wheat circular breads. We don’t use them in a wrap structure. We use them like a spoon, where you break off a piece and pick up the food with it. So, if you’re eating really spicy food, you’re going to use a lot of those to pick up the spicy side dish of yours. And the main hero of the plate was the roti or the rice, the carbohydrates.
By cutting down by 50%, from 8 to 10 of these per day, he was coming down to 4 to 5 of these. Each of those is about 15 grams of carbohydrates. You’re talking about 150 grams of carbohydrate just from these flatbreads, cutting it down to 75 grams. He and I were both excited and motivated by this, and so then started a journey, which we continued over a year, where we just kept bringing it down, pushing his vegetables and proteins up, because he was vegetarian. I work with a lot of vegetarian Indians who are protein deficient, so we focused on that, and we kept bringing the carbs down. I was able to get this man, who was failing on five drugs, down to one drug in a year and a half.
Dr. Eric Westman: Did you have a second patient?
Dr. Roshani Sanghani: Oh yes. That got me completely flipped on my head. I was like, “Oh my god, I’m not going to do that again. I don’t ever want to be the doctor who doesn’t give people this option.” I have to show them that if you want your glucose levels to come down with less medication, we have to talk about nutrition, sleep, stress management, exercise, and fasting. This come-together moment happened in 2014. By then, I had read everything I could find. I read things by you, I read Gary Taubes, Robert Lustig, David Ludwig, and then by around 2017 or 18, Jason Fung. All of this started to come together, and I started creating a multi-disciplinary approach.
I created a diabetes self-management education class. We called it DSME – diabetes self-management education – and I launched that in the hospital. It was the first time in Mumbai, India, that there was an endocrinologist-led diabetes education group session happening. I would cover back then the AADE (American Association of Diabetes Educators) and their seven self-care tips. I would teach people about all these lifestyle habits that would make an impact so they could achieve better health with less tablets and less prescriptions. No looking back from 2014 onwards.
Success with Patients
Dr. Eric Westman: And you’ve had good success with your patients?
Dr. Roshani Sanghani: Yes, yes. To the point where we brand ourselves as a lifestyle-first practice. We want to work with you over 3 to 6 months. We don’t do just the reactive, “Come when the glucose is high, take a scribble of a medication adjustment, and then off you go. I’ll see you in 3 months with fresh blood tests.” Not like that anymore. Now, we want to be highly in contact with you every 7 to 10 days. We’re with chat support, so we’re with the patient in those decisions that happen every time the patient leaves the doctor’s office. That’s when real diabetes management starts – when they leave. It’s habits. It’s ultimately habits and lifestyle that make a difference. They may not know what to do, and they’re so boggled by confusing, conflicting information – the mainstream noise. They don’t have clarity. Our job then became to give them that clarity.
Carb Ranges
Dr. Eric Westman: In your description of the dietary program, how many grams of carbs are suggesting – do you use total or net? How did you come about to that range?
Dr. Roshani Sanghani: Yes, that’s a great question. I just used total because we end up having a lot of vegetarians. They’re going to get a lot of fiber through their vegetables, pulses, and legumes. I wanted them to look at the total carbs first, at least, that whatever it is, I want to meet them where they are.
The other thing I’ve invested some attention and training in for myself is motivational interviewing as a coaching technique. That came from the addiction space. It was first used on people who struggled with alcoholism and drug use, but it has now entered into diabetes and mainstream chronic disease management because managing a chronic disease is so much about patient behavior. It’s not just about how intelligent my prescription is or my medications. I use that and meet them where they are. Yes, I have an idea of where I want their proteins, carbs, and macros to be, their sleep, stress, and everything. But if I just dump it at them one way, it’s not going to help them succeed. And I want them to succeed.
How do I help them? I start showing them. They basically start logging their current data into my app. It’s just a factual, non-judgmental assessment of what your total carbs and proteins are. I’ve put in a bit of scoring of my own. If it’s a highly processed grain, for example – like a loaf of bread that calls itself protein bread – I’ll teach the patients label reading. I’ll say, “Look, they’re claiming this much protein and carbs, but look at the other ingredients here, which are bound to cause inflammation and reduce the availability of your processed nutrients.”
We’ve kind of down-scored some of the claims on the nutrition labels based on Don Layman’s research on protein availability. If, for example, someone starts at 200 or 250 grams of total carbs per day and their protein is around 20 or 25 grams per day, we’ll say, instead of having them worry about “Oh my god, you’re going to take away my carbs,” they’re attached to the fact that, “That’s what gives me my fullness. I eat that big serving of carbs to feel full.” Then, they’ll be like, “You’re making me eat less food.” Remembering that people with high carb, high insulin are hungry all the time, and if I start taking away that, they’re going to feel nervous. So, let’s work on hunger by pushing protein up first. I’m telling them to eat more of something that usually works well is, “I’m asking you to eat more of this,” psychologically.
In your paper, where your team switched out 60 grams of protein, you guys went from a high carbohydrate to a high protein approach. The net difference was you chopped off 60 grams of carbs and replaced them with 60 grams of protein, and just doing that, people’s metabolism and parameters got so much better. That’s what we end up doing step by step. From 20 grams of protein a day, we go to 30, slowly. Slowly, because a lot of our patients probably have some gut microbiomes that are not great at digesting protein. There are a lot of digestive complaints so we have to go really slowly with them while reducing the carbohydrates as they feel more full. It’s not that I start with a number on day one.
Dr. Eric Westman: I’m going to bring in a little skepticism: How low can you go, or how high can someone still be and reverse diabetes, lose weight? The best studies we have come from Virta Health; our studies were long ago, but you can actually reverse and take people off insulin. I have to confess: If someone is vegetarian in my area or vegan, I say, “That’s not the set of foods I know.” I don’t know much about how low to go using just vegetarian foods, but I want to learn. Can you reverse diabetes with someone eating 100 grams of carbs a day?
Dr. Roshani Sanghani: That’s such a good question, Dr. Westman. I’ll tell you what I’ve been doing in practice: Because there is such a high prevalence of vegetarianism, just the same way that I had to offer my patient in 2013 the option of “Are you willing to reduce your carbohydrates if that gives you the chance of avoiding insulin?” I have to offer people the question: In India, vegetarianism is a very important cultural practice. I cannot just come in and swipe it away. I’m vegetarian. It’s very difficult. I have to work with what I’ve got, and I know they can succeed. I’ve reversed my own pre-diabetes with an HbA1c of 6.3. It’s now a 4.9 or a 5. I’m vegetarian, I’m low-carb, but I’m not keto. I can tell you later on, offline or somewhere, what I eat in a day. How do I work with people who are vegetarian? I have to offer them the possibility. If you’re willing to go with animal protein, you’re going to succeed much faster. It’s going to be easier if your gut will handle it better and your digestive symptoms will get better. It’s so much easier to achieve your protein targets with good quality protein, so many benefits.
Dr. Eric Westman: The tools you’re working with, to get the protein you need on a vegetarian diet, vegetable sources have some carb with it for the most part unless you just stick to tofu or seitan but you want to have more protein than just that.
Dr. Roshani Sanghani: Exactly. These are questions that I had to think about deeply and I cover them in detail in my book. I walk through each and every one of those problem cases that you just mentioned but I’ll walk you through it now. Yes, each and every legume or pulse or bean comes with about two and a half parts carb for one part of protein. If I take a serving of, let’s say, chickpeas or kidney beans, this might give me about 8 grams of protein but it’s already around 20 or 20 plus grams of carb right there. I will hit more than 100 grams of carbs a day before I even reach my protein target. If I have to get some to 90 grams of protein while eating beans they’re probably going to be around 200 to 270 grams of carbohydrates a day so that’s not going to help them succeed.
What I have found works is if I can get their carbs to 80 to 100 grams total per day with the protein at target. That’s usually not enough just in the nutrition bucket so I end up working on four – I call them four wheels of the lifestyle car. Think of the four wheels, if any one of them has a flat tire you’re not going to get to your destination. I use that car analogy in my book and through my practice. Nutrition is one of the wheels. We have other wheels. The idea of glucose management for diabetes is not just glucose. You have to think of three organs – there’s the liver, there’s the muscle, there’s the pancreas. Manipulating food is one piece of it but there are other things we can do to help these three organs – how’s our sleep, how’s our stress management, how’s our exercise and strength training and then fifth point being intermittent fasting.
Once your four wheels are okay then we can add intermittent fasting because what I don’t want is a protein-malnourished, non-exercising, poorly slept, stressed out person trying to fast. They’ll say, “Fasting didn’t work for me.” The way I have to achieve keto and autophagy is through fasting because it’s more difficult for us vegetarians to achieve and sustain nutritional ketosis without adding in the fasting.
Catering to Vegetarians
Dr. Eric Westman: Very interesting. I really love your book, Turn Around Diabetes, because of the vegetarian approach. I mean the contrast with the books on carnivore – there’s not much nuance to eating meat. Your book helps going through even the carbs per protein calculation. When you learn a few things like that it becomes a lot easier.
Just stepping back, what’s the estimate of how many vegetarians there are in India alone?
Dr. Roshani Sanghani: Oh my gosh, I wouldn’t know the exact number but there are a lot.
Dr. Eric Westman: More than Americans?
Dr. Roshani Sanghani: Oh yeah, for sure, for sure.
Dr. Eric Westman: When you step back, we have to be able to have folks like yours who ethically, morally, or for religious reasons choose vegetarian lifestyles.
Dr. Roshani Sanghani: Yeah and they don’t have to be stuck with progressive diabetes just because of that one food choice. We may have to work harder on the other areas because like we were saying it’s so much easier to just go for animal protein everything starts to get corrected quickly, but if we’re going to take take the vegetarian road we have to be very meticulous, very careful to get that balanced, healthy approach that can sustain. We’ve seen that. I’ve built my entire practice around this. This is exactly what I solve for every day. My social life is ruined because every party I go to people are asking, “How do I get protein?”
Dr. Eric Westman: These days to relax the crowd I usually have a little bit of carbs and I say, “I’m off duty,” and then people relax.
Non-Dietary Tactics
Dr. Eric Westman: Regarding the exercise component in your practice, do people in India jog?
Dr. Roshani Sanghani: I live in Mumbai, so it’s a big city, and the number of jogging tracks or dedicated walking pathways are not sufficient.
Dr. Eric Westman: Let’s talk about non-dietary things that you incorporate.
Dr. Roshani Sanghani: Yes. So, we do see runners. There are jogging and running communities. There are a lot of marathons, ultramarathons, triathlons – all of that stuff is happening here.There is a fitness community that’s into that stuff, but for the average citizen walking around the streets, they may not have access to safe jogging or walking tracks. We need to help them with other things.
People are very familiar with walking when they get a diagnosis of diabetes, they start walking, and that’s a great thing. The other thing they’re okay with is doing yoga. There’s a lot of acceptance for yoga, and I’m fine with yoga. I just feel like there’s going to be a plateau. I had to go take the certified personal training course from the American College of Sports Medicine myself because, again, in med school or in fellowship, I didn’t get any time being trained in exercise. Didn’t know anything about it. We studied fractures and bone tumors, but we never had exercise understanding.
Strength training to build muscle mass – I didn’t realize until so late in my career how important that is from a hormone management or from an endocrine perspective. I feel bad. I feel embarrassed that we didn’t know these things in a practical way. It was something I knew from physiology, first-year med school, but it caught dust and went away somewhere in the attic in my brain. We do talk to patients about strength training, and there is more access to gyms where you can have a membership. There are personal trainers who come home to train you in your house. There’s a lot of physical therapists also who get people gym-ready because, unfortunately, with the sedentary lives and indoor lives that a lot of us have taken to, a lot of people have aches and pains. They don’t know posture. They don’t know how to engage their core, even when we stand. Even I didn’t know how to engage my core. I’ve spent a lot of my time at a desk studying practice. I’m not an athletic lifestyle as such. I exercise because it’s good for me, but I have a lot of sedentary habits myself, and I’m always working around that. We have stiff shoulders. We’ve got stiff hips and knee pains.
Accessing a physical therapist is another thing. Another thing people do here to get gym-ready is first learn how to set your shoulders neutral.Get your neck in the right alignment. Get your spine to be neutral. Many of us don’t know that. How to do diaphragmatic breathing or sitting and activating your legs at your desk. Like, even that non-exercise – just fidgeting, bouncing your heels under your table just to activate your calf muscles. There are so many ways we talk to patients, and then we help them take it to the next level once they’re mentally ready and accepting of the idea of building muscle. Because in India, still, I hear this a lot: “I don’t want to be a bodybuilder.” You’re not going to get to be a bodybuilder anytime soon, trust me. They’re like, “Oh, at this age, why do I need to go to a gym? That’s for somebody else.” They don’t associate frailty of aging as something that can be prevented.
We’ve got a lot of multi-generational families. We’ve seen our grandparents get old and frail and cared for by the middle generation, so there’s almost like this acceptance of decline. I’ve seen life in America where people are more independent, where they’re not counting on that, “My kids will keep me in their homes when I’m 75, 80 and weak.” It’s a different mindset about what aging looks like.
Dr. Eric Westman: Has the cult of pickleball hit India yet?
Dr. Roshani Sanghani: It has! I just saw pickleball set up right close to my house. It just came up recently, so pickleball has come. There are a lot of fitness-related games. We have cricket, so people like to play. They like to play. Humans like to play. We put them in schools, and we lock them into desks for eight hours, and we just mess up what childhood is all about. I think that’s happening everywhere, but the acceptance of play and movement is there, and a lot of fitness awareness is available. A lot of exercise startups are available. Online workouts, so there’s a lot of excitement happening in this fitness space in India as well.
The Importance of Sleep
Dr. Eric Westman: So much can be accomplished by diet alone but how do you handle the sleep? And why is sleep important?
Dr. Roshani Sanghani: Sleep is such a big one. In my four wheels of the car, I sequence it in a way that nutrition is the first wheel, sleep is the second wheel. I don’t even come to stress management or exercise until we’ve addressed sleep. I’ll tell you the top two reasons.
One is there’s something called sleep apnea, which is a snoring-related problem. Although we associate it with being overweight and really large and heavy and having a neck or a tongue that causes us to choke in our sleep and cut off air supply, I see in my Indian practice more petite body frames, smaller builds – not BMIs crossing 25 or 30 – and they’re having sleep apnea, and it’s undiagnosed. They’ve got this chronic fatigue, and they’re not fresh. If you’re not slept well, everything the next day – whether I tell you to exercise or eat right or fast – if your brain is just not fully charged from a good night’s sleep, you’re going to really struggle to do anything new or learn new habits or resist cravings, for example if you’ve just got an under-rested brain. That’s one, is I look at sleep apnea because it’s underdiagnosed. I think sleep apnea also explains a lot of non-obese high blood pressure in this country. We see slimmer people with high blood pressure, and I’ve seen that it gets better when we look into sleep apnea.
The second one is that India is a 24-hour economy in the sense that we serve parts of the globe at all times. So, people are on screens, their body clocks are fully disrupted. They don’t experience natural sunrise and sunset. Being a hormone doctor, we know about jet lag, which is melatonin – that’s a hormone, that’s the jetlag hormone. We don’t have access to that to give us our daily sleep rhythms and our daily 24-hour body clocks. Losing that has also been connected to poor metabolic health. Whether you call it weight gain, difficulty losing weight, more cravings, less satiety, more hunger the next day, and of course diabetes and blood pressure. Even the NHANES study looked over time and showed that sleep caused more difficulty losing weight and more hunger pangs.
Sleep is big and just by making some small changes there – having worked on nutrition and then sleep – now I have somebody who comes in saying, “I have more energy, I have fewer cravings, I am thinking more clearly.” The brain fog is beginning to lift. It becomes much easier to then talk about stress management and exercise.
Managing Stress
Dr. Eric Westman: Yeah, that’s wonderful. So, the fourth wheel, stress management – how do you handle the 24-hour day culture?
Dr. Roshani Sanghani: It’s so tough. There are so many ways to answer that. I think we would need a whole hour minimum to go into depth and do it justice. But I’ve gone into this in many ways myself personally, and I think that helps me make it more real. It’s not easy to tell someone to “get a grip” or say, “Well, just fix your stress,” because stress is a combination of what’s happening in the external world that’s not going my way, maybe, and also how I’m reacting or responding to it – how my mind is processing what’s going on. I had to learn my own spiritual journey first.
In 2013, a lot of things happened. There was this one man who had said, “I’m not going to take insulin.” In parallel, alongside that, I was having an internal stress peak in my life. I was almost getting to the point of, “Oh my gosh, I don’t know what to do. I’m out of ideas on how to solve this stress of my own, personally and professionally.” It was a dark moment. I came across a meditation technique. I started using it because I had reached my wits’ end. I was like, “My intelligence is not helping me feel happier. I just want to be happy. I’m unhappy, and I’m tired of being unhappy. I’m willing to do whatever I can do.”
Somewhere, something clicked. As long as I’m waiting for these external things to change so that I can be happy, I don’t have the keys to my happiness. My keys are lost somewhere. I can’t be happy because no one’s doing what I want. The world is not giving me what I want. I wanted to get the keys back.
As my meditation practice started, again, being a curious, bookish, geeky sort of person, I went into so many books. Some wonderful books like Eckhart Tolle and Michael Singer. My own culture from India – deep spiritual backgrounds in India as well – talking about meditation or even God is not an awkward thing to discuss in this country, at least. It doesn’t have to be God. It could just be that you deserve self-care and self-love. It could be just that. That’s all it really takes, honestly, to find that inner peace and quiet.
Depending on how the person comes in, I address stress management in different ways. Again, I had to get trained in emotional eating. What is mindfulness? What is mindful eating? What’s my relationship with my food? What’s my relationship with my body? How do I talk when I see myself in the mirror? Do I like what I see in the mirror or on the weighing scale? Or do I hate what I see? Because my thoughts – this is the neurology and endocrinology linked together, or psychology and endocrinology linked together. If I’m thinking negative thoughts, I’m feeling negative emotions. That’s setting up negative hormone responses in my system. I might have a difficult environment. I might be living under very challenging circumstances, and that could be affecting my well-being. But within myself, these are the things I have control over: my thoughts.
Depending on how much I can build rapport or trust – and again, because I have this reputation now of being holistic, being overall comprehensive – there is that little bit of access where I have permission to go into these sensitive areas. We’ve kept a spiritual therapist in-house. We have a spiritual counselor who will go through a guided mind-body session. For example, let’s say somebody says, “I have a sweet tooth,” and they want to get rid of the sweet tooth. They don’t feel powerful in front of sugar; they feel powerless. They logically know they should stop, but they feel like it just sort of comes at them. This urge to consume sugar just takes over – it’s like an emotion, like a tidal wave, knocking them flat. They’ll go through a session with our therapist, and maybe it comes up – if they’re okay with going there – old memories, old associations, old unhealed emotional aspects that were showing up under sugar. Until we address those emotions, it’s very difficult to have them just stop sugar. That’s just one example.
Dr. Eric Westman: Most people don’t know that I’m the son of a psychiatrist. Not that I am one – I rebelled against something that didn’t have numbers and all that. But the mind is connected to the body. It’s hard to bring that up in the American setting, I have to say, for various reasons, although some people are open to it. That really does become such an important part of the wheel of stress management in your framework, which is fantastic.
Sometimes, it’s like a bait-and-switch. Someone comes in: “We’re just going to talk about diet.” Then you bring up, “What? Religion or spirituality? What is this? I thought this was a doctor’s office!” But then people don’t think it’s a doctor’s office because I talk about food.
Dr. Sanghani’s Book – Turn Around Diabetes
Dr. Eric Westman: I can’t say enough good things about your book. It’s no small feat to write a book. How did this come about?
Dr. Roshani Sanghani: I can tell you briefly. I’ll say I’m a daughter of a psychiatrist also. And, believe it or not, I did a year of psychiatry before coming into internal medicine. One of my interviews was at Duke, and I met Dr. Grace Thrall way back. Look at how I’m still talking to someone from Duke about mind-body or the connections between thoughts and health even today, more than 20 years later!
To come back to the book – it was like I knew it had to get out of my head. It just needed to. In Harry Potter, Harry takes the wand, and he does that thing where he puts ideas into the bowl? I needed these ideas to get out of my head so I could see them, share them. If I’ve gone through this much effort doing diabetes education training, certified personal trainer training, spiritual growth, mindful eating, just accumulating all these multiple things, I needed it to be out there. It’s not easy to come up with such a multifaceted way of seeing things, and I thought, “This perspective is rare. It needs to come out.” I pitched to publishing houses for two years. While I was writing the book, nobody took it up. I pitched to Indian publications and agents and to United States publishing houses and agents. For whatever reason, it just did not get picked up. I finally self-published. I went with the self-publishing route last fall, and the book hit the stands this June. It’s done but it was a four-year process of writing.
Dr. Eric Westman: Yeah, excellent. I love it, and I think it’s going to help a lot of people. If you’re not getting that feedback already, it’ll come. It takes some time and marketing. I would highly recommend that people check out your book, especially if they have a vegetarian epic or desire.
Do you use this in your practice? Is it that much of a guide, or is it more for someone to read who hasn’t come to your practice?
Dr. Roshani Sanghani: Both. It works both ways. The person doesn’t have to really use the book if they’re with me in our coaching and consulting. A lot of things we’re saying on screen or on our Zoom calls are in the book. I might go back and say, “You know what? Do you have the book? This is page this,” and they’ll have time to really soak it in. Some of them will say, “Yes, I’ll get it.” Some of them will say, “I have your book, and when I read it in my free time, it feels like you’re talking to me. It feels like you’re in the room.” It goes both ways.
I’ve seen people discover the book or read it and have nothing to do with my practice. They find they’re already working on changes on their own without needing to see me or work with me. Of course, if they’re on medication, they should work with their doctor because there might be implications if they’re on prescriptions but it does work as a book just for your own healthy lifestyle. I use the word “diabetes” in the title, but there’s so much in there for people who want to prevent diabetes or avoid diabetes as well. There’s even a dedicated section for type 1 diabetes.
Dr. Eric Westman: Fantastic. You can’t beat your credentials, you know. And yet the information is more self-taught and learned through patient experience and your own experience, which I find is a recurring theme for those of us who learn from others or through our own, not through the medical system so much. I’ve gotten to the point of throwing up my hands in trying to surmount the fortress of pharma, which has infiltrated and taken over medical educational programs. Is that your perspective, or the way you’ve put it together now?
Dr. Roshani Sanghani: Oh yeah, it is true. I’m thankful that people like you are still at universities, able to do things, and your research helps us. Virta’s research, your research through Duke – it all helps people like us because otherwise, we’re just doing things that aren’t evidence-based, and we’re putting our careers at risk.
But yes, the pharma influence is quite strong. Dr. Westman, I should say that I was invited to write a chapter on lifestyle change for a cardiology textbook. I had given a talk to cardiologists across India – more than 400 of them – who wanted to hear about diet and exercise in preventive cardiology. They liked the presentation so much I was invited to do a chapter in their upcoming book. I did it, and I got a copy of the book as complimentary. And it’s a book, it’s an actual book. But when I received it, there were glued-in drug ads inside the book. Now I know who paid for the printing costs. It’s a book, and it’s been sponsored by pharma.
Final Thoughts
Dr. Eric Westman: Any final thoughts? Otherwise, thank you so much for taking time to speak to me.
Dr. Roshani Sanghani: Yes, I’d love to stay connected. I learn so much from the work all of you do. It’s been nice. I was at the San Diego conference in August, and your name came up so many times in that meeting. I was so thankful to have the support from you when I was coming out with this book. For me, it was almost like validation to come out from India and meet everybody there, not feel so alone in this community, and feel that network of support. Thank you for today and for your time.
Watch the full interview here.