Episode 37: Prescribing the Ketogenic Diet ft. Priyanka Wali

August 17, 2017

"Let food be thy medicine and thy medicine be thy food."

Episode 37 features Dr. Priyanka Wali, a forward-thinking doctor who is experienced with guiding patients through a prescribed ketogenic diet. Originally a vegetarian, Dr. Wali is now an advocate of the ketogenic diet. She's helped those with diabetes to those simply curious about the diet for health optimization purposes. One such biohacker Dr. Wali personally guided was Business Insider's own Melia Robinson, who recently wrote about her experience being keto.

Geoffrey Woo and Dr. Wali discuss the rapidly growing interest in the ketogenic diet, why more doctors should view nutrition as an integral part in health and medicine, and Geoff's experience fasting for seven straight days!

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Transcription

Geoff: Hey, Guys. Welcome to this week's episode of the THINKING Podcast. This is your host, Geoffrey Woo. I'm excited to have Dr. Priyanka Wali here with me. Interesting story of how we met. It was at the World's Fair SF, and I gave a talk about biohacking, and part of the talk was about keto, low carb high fat diet, and ketosis, and I met you in the context of you being a comedian. You also happen to be a fully licensed, practicing doctor.

Priyanka: Yeah, the reason why I was at the conference is there was a comedy show happening at the conference. It was called Eureka, and it's a science-based comedy show, so I was one of the comedy commentators for the scientist that was there. I was killing time and I saw the roster of different talk, and I just walked in and sat down and then you came up. I think I saw the second half of your spiel. You were preaching to my choir when I was listening to you. I was like, "Where am I?" I was like, "I have to introduce myself to this guy." It was kind of funny because I had all my comedy cards with me. I had none of my medicine business cards, so I'm like, "Look, I'm here for comedy but I am actually a keto physician, and I totally get what your doing and I think it's awesome." I think it was a really cool story how we met. You connected me to Manny.

Geoff: Yes. Manny is a clinician who's also been on our podcast a couple of times. I think there's just an emerging group of physicians who are looking at the existing care system and going, "Hmm, some of the basic biochemistry doesn't quite make sense. It's now making sense from a textbook level as well as a practice level. Let's see how to improve the system. I think there's a very quickly growing group of practitioners and clinicians that are starting to have their light bulbs turned on here.

Priyanka: Yeah, for sure. After Manny and I met, and we pow-wowed and we shared thoughts and whatnot. It was great to connect with him.

Geoff: I think recently, Melia Robinson from Business Insider has been covering this broad beat of bio-hacking and she approached me asking, "Hey, I want to try this ketogenic diet that I hear that all of these Silicon Valley execs are doing," and I was like, "Hey, Dr. Wali is up to speed on this. Talk to her and then she can be your guide into this world." It sounds like that was one of her most viewed articles. That also speaks probably to the interest everyone has about hacking ketosis.

Priyanka: Yeah, for sure. It's funny because when I first met Melia she was a little skeptical. She was like, "What is this?"

Geoff: Is it insane because the current dogma is like, "Fat is not good. I'll let you explain."

Priyanka: Exactly. When I first met with her I went through her entire medical history and I was like, "Look, there's no absolute medical indication for you to be on this. So, I need you to understand that in my practice, I'm putting patients who need to be on this, like people with diabetes, pre-diabetes, metabolic syndrome, fatty liver, polycystic ovarian syndrome, you name it." So, I was like, "This is helping a lot of people, so whatever you're going to write you need to make sure you don't bash this because this is actually helping a lot of people. This is treating people. I'm getting people off meds." I sat her down and I was very like, "Look, you don't have a medical indication to do this, so if you're gonna do this you need to be respectful of what's going on here-"

Geoff: On the therapeutic side.

Priyanka: Yeah. Because this is helping a lot of people. So, after I kind of explained that to her I think she was much more appreciative and mindful. Then we also didn't go immediately into hardcore ketosis overnight. I realize we should wean her into it, gently put her in ketosis, which we did. You can read the article.

Geoff: We'll link to the article. Yeah.

Priyanka: The article is awesome. She did a great job in talking about it. There was a little Twitter flack that I got from some other physicians that aren't really familiar with it. But, I straightened that out. There were a couple of comments like, "Are we promoting weight loss, or are we promoting health?" I was like, "Dude, it clearly said in the article that I told her that this wasn't an absolute medical indication for her to do this." This was an and of 1 experiment that was documented. I don't think ketogenic diet is for everyone. I am not the type of person that this is the world's diet.

Geoff: I think that's an important thing to explain and talk about when we talk about ... from a therapeutic use case, to an enhancement use case, or bio-hackers use case, a lot of these are subjective n equals 1. You should be measuring your own biometrics and your own experiences with it. I think it's over prescriptive on the other side to be like, "Okay, let's go away from low fat, and let's eat a ton of fat." I think that's equally as dogmatic as the current system. Let's not make the same mistake twice.

Priyanka: Exactly. I think it's important to be skeptical always, right? It was really cool following Melia. We would touch base via text but then meet in person, and a couple weeks into it she just seemed so much happier, she was glowing!

Geoff: I saw her recently and she was saying that she just felt a lot better. Which I think is a lot of the subjective feeling that a lot of our community members that are on keto, or playing with fasting, feel. I think that's why it's a growing movement where it's something you can do, it's something that's free, and it's something that's relatively free because you're just gonna spend money on food anyways. People are seeing good results from it.

Priyanka: Like I say, if you have diabetes or pre-diabetes it's a pretty strong, if not absolute, indication-

Geoff: Yeah, I'm curious. Before diving into the weeds into the indications, I'm curious how ... your background, your history into this? I think-

Priyanka: Like how I discovered it?

Geoff: Yeah. Because I think a lot of clinicians, doctors, that I talked to, they go through medical school and residency with the existing dogma of ADA requirement, and it sucks, and that's very different from what we're seeing in practice as a results. So, I'm curious to hear your background story there.

Priyanka: Absolutely. It's actually pretty interesting because in med school I was a good little med student, I followed on myself The American Heart Association guidelines, The American Diabetes Association guidelines. I was eating a low fat, lacto-ovo vegetarian diet. I thought animal fats were bad.

Geoff: Where'd you go to medical school?

Priyanka: USC in Los Angeles.

Geoff: Grew up near L.A.?

Priyanka: Yeah. I was the good little med student. I thought I was doing this because I was reducing my risk of heart disease. Mind you, I was hungry. I was hungry all the time. I just thought hunger was a part of life. I just accepted it. Then, flash forward, I'm in residency here in San Francisco. I'm looking to moonlight, and I just need to make some extra money so I can pay rent.

Geoff: What was your specialty at this point?

Priyanka: Internal Medicine. I did it at California Pacific Medical Center. I'm like a scrappy resident, on a resident's salary, I'm trying to make rent so I'm looking for moonlighting opportunities. I come across this weight loss clinic. This clinic is basically putting these patients on what are called VLCDs, or very low calorie diets. So they're feeding these patients meal packets, and they're eating about 800 calories a day, and these guys are losing massive quantities of weight, and they're actually in ketosis, but I didn't put it together at the time. One thing I did know was that with these VLCD programs the majority of these patients, once they stopped the program ended up gaining the weight back. So, I knew that you can lose a bunch of weight by getting on this VLCD, but-

Geoff: It's like starvation, kind of.

Priyanka: Yeah, it's ketosis. But, it's not sustainable. You can't eat these packets for the rest of your life, like these little meal packets and shakes, very processed, very American. You know what I mean? Totally packaged.

Geoff: Also, if you're just eating calorically restricted it slows down your metabolism, right?

Priyanka: Exactly. I got really interested with weight loss and obesity medicine because of that experience as a resident. Then I graduated, I went into practice, and again I was doing everything by the book like a good little attending, following the ADA recommendations and I started to notice that all of m patients with diabetes, they didn't feel good. They weren't getting better, they were just sort of staying sick. Every time I put them on insulin they would gain weight, they felt terrible, they're blood pressure would go up, and I was kind of like, "What the hell is going on? I'm doing everything by the book, their numbers are getting a little better, but they feel bad."

Geoff: They're just stagnating.

Priyanka: They're stagnating. So, I was like, "Okay, I need to figure this out." I was already into understanding weight loss and ketosis because of the VLCD, but I knew there wasn't a maintenance answer in that so I started looking for other options. I went back to the literature, I started speaking to other physicians that had experience with weight loss, and then I discovered the science behind low carb diets, ketogenic diet. The first time I heard about the ketogenic diet, the science made sense to me but it was so outlandish, the idea of eating so much fat, I was like, "Okay, scientifically this all checks, but it's the opposite of everything I've been told. At that time, I was lacto-ovo vegetarian, I was like, "You know what? I'm convinced that I should put my patients on this but I better try it on myself first because if, God forbid, there are any reactions, if I have a heart attack I can recover from it. I'm pretty young. I'll just do it." Initially when I started doing keto because I was vegetarian I was doing vegetarian keto.

Geoff: That's not easy to do, right?

Priyanka: It wasn't easy at all, it was actually really hard.

Geoff: So, what were you eating?

Priyanka: I was eating tons of eggs and cheese.

Geoff: Avocados?

Priyanka: Avocados. Then something happened in my brain. I cut the carbs and something switched. I was like, "I need to eat meat." But I hadn't eaten meat for years so I was really confused about it. So, I actually gateway transitioned with oysters. I had to talk myself into it. I read this article on Slate, which was published seven years ago, talking about how you can be vegan and still eat oysters because from an environmental standpoint it's still sustainable, and oysters have very poorly developed nervous systems, so it's even debatable whether or not they feel pain. So, I created all these justifications, then I ate oysters. Oh, my God, when I ate oysters I just started to feel even better. So, oysters, then I transitioned to mussels, then fish, then everything. Now I eat everything. Then I went full keto in terms of increasing my meat intake. What I started to realize is I just felt better, and better, and better. Mind you, at the time I was doing standup comedy. I was a resident, then I graduated. I would work in the clinic all day and then I would perform at night doing shows. Before I went keto I was exhausted. In fact, during my lunch break at 1 pm I would go to my car to lay down for 20 minutes. I just thought, "I'm just grinding too hard." You know what I mean? I thought I was just working too hard. I switched to keto and the first thing I noticed is, "I don't need those damn naps anymore."

Geoff: Your energy was consistent throughout the entire day?

Priyanka: Yeah. I could work during the day and I would perform at night, and yeah I would be tired because I would be still not sleeping as much, but it was clear to me that my sustainability totally changed. Once I put myself on it I was like, "I'm totally fine." By the way, my cholesterol numbers, the ratios all improved. I didn't have any metabolic syndrome to begin with. My hemoglobin A1C went from 5.4 to 5.0. and then my cholesterol ratios all improved. They just got more optimal.

Geoff: To give a sense, pre-diabetic range for H1Bac is ... ?

Priyanka: 5.7 or above.

Geoff: Then diabetes is like 6.2?

Priyanka: 6.5 or higher is diabetes. Then I started putting my patients on it, and very quickly within a few months my practice started to become so much more satisfying because I was getting people off meds, cutting their insulin down, if not cutting it off. People were losing weight, people felt better. They were thanking me, I was getting more hugs than I ever got in the clinic. What's funny is that a lot of my staff secretly started eating low carb without telling me and they all look great now. It was awesome. It was very cool. Now, here I am. Yeah.

Geoff: Yeah, that's a crazy story. To be a devil's advocate, I've heard of some people that see increases in triglycerides, cholesterol. It seems to me that there is probably some genetic, or some factor there that's for some people. I've also heard of the other on some people where it doesn't affect their fatty acids.

Priyanka: Typically you'll see triglyceride levels go down, and that's typically a sign that circulating fat in the blood stream is being utilized for ketosis. Typically, triglyceride levels go down but you can see elevations in total cholesterol, like isolated total cholesterol. Sometimes, LDL does go up but you want to look at your LDL particle size because just because the total LDL goes up doesn't necessarily mean that the particle size ratios have become adversely affected. If someone's actually eating a true nutritionally adequate ketogenic diet, we typically see drops in triglycerides. But, you can see elevations in total cholesterol and LDL. I agree with you that it could be a genetic thing.

Geoff: That's why I think it's important, on the bio-hacking side, actually measure these things.

Priyanka: Absolutely.

Geoff: Right? Because if you're not measuring you're just kind of shooting in the dark. But, if you're just actually seeing your metrics approve across all boards, I think there's at some level, just trade offs. I think the body is designed to stay in homeostasis. So, if you're just pushing levers around you might shift other things in different directions. I think it's finding overall balance that makes sense for oneself.

Priyanka: Totally. I've talked to Steve Phinney about a couple of my patients who's cholesterol went up in the past, just to kind of run it by him. What's funny is that we tend to see these elevations in young, healthy males who don't have metabolic syndrome. Those are usually the ones that I notice that their cholesterol levels go up. You could check the ferritin level. Sometimes if their ferritin is too high maybe they are eating too much meat, that is possible. I remember this one guy from Argentina, I put him on a low carb diet because he had fatty liver, and his cholesterol numbers did go up, and I checked the ferritin, his ferritin was slightly elevated, and I was like, "How much meat are you eating?" He's like, "Well, dude. I'm from Argentina. I'm eating steaks all the time." I was like, "Look, take it a little easy. You don't need to eat so many steaks."

Geoff: That's a good point. I think it is very hard to stick to a true keto diet. A lot of people overeat protein too much and, as you know, protein breaks down to amino acids, which turns into sugar through gluconeogenesis. So, I think that's the process in which it's not okay to just eat steaks all the time. If you're eating steaks all the time you're not going to be truly ketonic. Measure your blood ketones, you're probably not gonna be that high.

Priyanka: I still don't understand how some people can tolerate high amounts of protein whereas others can't. It's not across the board. There are some people that eat tons of protein and their insulin levels won't necessarily be affected. I don't understand that, but I think it's very cool that we're so individualized. I feel like good medicine is individualized medicine. You can't apply these guidelines to every single person, which drives me nuts because right now our health care system, which is insurance based managed care, it's all based off of these generalized guidelines.

Geoff: These guidelines are on clinical trials that are primarily white Americans. Because that's what the clinical trials are done on. Clearly there's probably some genetic difference in reactions from an Asian population, an Indian population, a Black population, right? So a lot of the clinical trials on the meds are done because the sample sizes tend to just be of a certain demographic.

Priyanka: Medicine is racist everybody.

Geoff: I think it actually is. I don't think it's from a malicious perspective. Most psychology studies are designed on 18 to 22 year old college Psychology students, because that is the population that signs up for these trials. These are not a malicious perspective. Clinical trials are hard to run, and what are the easiest samples to run them on. Well, it's like whoever is available, and in America for most of the clinical trials that are done, that's gonna be a Caucasian American of a certain socio-economic status. It is just what it is. But, I think that doesn't mean that's the one size fits all. Let's get smarter, let's realize this is an institutional construct and get smart about it.

Priyanka: Yeah, I more research with more diverse populations for sure, and this doesn't just apply to metabolic health. Even in psychiatry for example, lots of different studies that have been done out there tend to be done with middle class white people, so that's very interesting.

Geoff: A lot of the trials are also done on men. I think that's another thing the men and women, most clinical trials were done on men. Seeing results is already hard enough, and for certain indications, women have menstrual cycle and if people are on different cycles that affects a lot of things, it's more complicated to net that out, so a lot of the trials are done on men. You can slice the bias on a lot of these trials in a lot of different ways.

Priyanka: For sure. Which is why again it's very important whenever you read something in the news, like check the sources, go to the original journal article, read the various-

Geoff: But, people aren't gonna read. It takes more and more people like us in the community out there to educate themselves and help educate people around them.

Priyanka: That's so true. We've got to get rid of all those alternative facts out there.

Geoff: Yeah. In terms of ketogenic diets, have you also looked at fasting? They're essentially attacking the same issue of raising ketones just in different pathways.

Priyanka: For sure.

Geoff: I'm just curious in terms of all the levers in your practice, how do you play with all the different levers?

Priyanka: I know you're big on fasting and stuff, which is awesome. Sometimes I'll use intermittent fasting in certain patients with diabetes as an adjunct therapy, meaning they're already eating low carb. I might implement as an adjunct if, let's say, they're plateauing. Some patients ask me about fasting and I tell them if they want to do it, go for it. I definitely tailor it. I won't approach it unless I feel like a patient would be open to it. It's already so hard eating keto in the food environment we live in, to then add fasting if someone's still struggling with eating keto. If they're open to it then that's awesome. I just kind of meet people where they're at, basically.

Geoff: That makes sense. You have to fight your culture battles one at a time. If you're saying, "Hey fast. Don't cut out all the yummy pastas." It's like, "I can only do one thing at a time."

Priyanka: I know. But, some people are really open to it.

Geoff: I think some people are just like, "Shit, I'm fucking dying."

Priyanka: For sure.

Geoff: "I want to fix myself. I want to try everything."

Priyanka: If people are motivated that's huge. That's really awesome. I think it can be more helpful if you have a buddy, or if families are doing it together. What's interesting is that in a lot of major religions fasting has been a part of certain religious activities like Islam, Hinduism, Buddhism, there's a lot of various sects-

Geoff: Like, Jesus or Moses fasted in the Bible for 40 days. In almost every single tradition-

Priyanka: Which I think is really interesting. Why or how that came out.

Geoff: I think, just looking at the literature, there were stories about Aristotle, or Plato, asking their new students to fast before coming to the academy because fasting purified your spirit, and like made them smarter to absorb more material. It's interesting.

Priyanka: So, like maybe they were in ketosis and they could have more fascinating conversations?

Geoff: Yeah, I think that's the theory. I think some of the interesting biochemistry there is that, I don't know if you've seen the literature but ketones actually burn 28% more efficiently than glucose, perseming of oxygen. So it's actually interesting from a biochemistry level that these alternate fuel source for the brain shows different power generation perseming of oxygen.

Priyanka: So, like in India where my family's from, in north India, Kashmir, there's these stories of these super wise spiritual guys that would go to the mountains and they would essentially fast, and not eat and then they would talk about the stuff that they learned, and they would pass down all this wisdom. I wonder if they were actually euphoric from-

Geoff: Being super ketotic?

Priyanka: Ketotic, yeah. They always talked about clarity of mind, peace of mind, stillness, joy, and they all spun it with a god, like this is all God. But you kind of wonder if someone's up in the mountain, and they're also cold, so then there's cold thermogenesis going on as well. You wonder if that's actually what's going on if you get into higher levels of ketosis. I've never actually-

Geoff: Do you measure yourself? I'm actually curious. I was gonna just ask you about that.

Priyanka: I teach a trial right now at UCSF at the Osher Center of Integrative Medicine. We're talking people with diabetes, putting them on a ketogenic diet, and we're randomizing one group to getting mindfulness training or not. The participants in that trial need to be checking their ketones three times a week. I've only been checking my ketones two times in my life. One was at a low carb conference-

Geoff: We have the kits here, you want to get-?

Priyanka: Yeah. While I'm here, I'm curious. Yeah, we'll see because I had a bit to drink last night so we'll see if that affected me.

Geoff: It's probably gonna affect you a little bit.

Priyanka: At the low carb conference, that was really funny because I think I was 1.4 then. For the UCSF trial I was 1.5 and then two.

Geoff: Okay. Legit. I think a lot of people that I test, they're like, "I eat keto." I test their blood they're like 0.3. I'm like, "You're not a keto."

Priyanka: Oh, interesting.

Geoff: You're not a keto. So, I think it's very hard to eat keto. I think people are like, "I'm just gonna eat steaks or whatever." But, then a lot of the sauces have sugar.

Priyanka: Sauces, man. Oh, the sauces.

Geoff: Or eat too much steak, and you start having the protein breakdown into sugar. You gotta legit eat fat.

Priyanka: Yeah, for sure.

Geoff: So, if your doing consistently above one that's very good.

Priyanka: Melia was telling me you chase the numbers sometime. What's the highest you've ever been and how did you feel when you were that high? I'm curious.

Geoff: The highest I've ever been is 5.5.

Priyanka: Oh, my God!

Geoff: That was through fasting for seven days.

Priyanka: That's incredible.

Geoff: No, it's insanely high.

Priyanka: Did you feel euphoric? Did you find God at 5.5?

Geoff: No, I felt surprisingly sharp for not eating for seven days, I think, five years ago when I didn't think about fasting or ketosis at all, I would have been like, "Dude, that's insane. You're gonna die."

Priyanka: Right.

Geoff: That was a very interesting week where I was traveling. This is in January, over a hundred people in our community did a seven day fast with us actually. Half the team here at HVMN did a seven day fast with me. The other half tried and failed after three days. I was jet lagged and tired but I didn't need that much sleep, I was super sharp, and was super primed for that week. I was actually working out during that week as well. I felt pretty strong, actually. I was able to maintain a lot of my lifting. It was interesting.

Priyanka: How was your mood?

Geoff: Hunger tapered off at day two, day three. I think after a certain level of ketones your appetite diminishes. The mood was very clear, very sharp. But at a certain point it was not optimal for productivity because you're so glycogen depleted, right? I think at a certain point you're just starving and potentially losing lean muscle tissue. There's probably a balance.

Priyanka: Did you find yourself sensitive to loud sounds, or loud lights, or just any other things? Were you a little bit more sensitive to your environment?

Geoff: That's a good question. I didn't actually pay attention to that. I don't think that there's anything that popped up. No. But, I think in terms of general acuity it felt like I was just sharper than normal.

Priyanka: I would assume that with a sharper acuity you would be picking up on stuff. One of the things I noticed when I first ate keto, I felt like I was in ketosis, number one, I felt very euphoric. But one of the things I really remember is that I turned on the radio and when the music was playing it was like I was feeling really overwhelmed by hearing the music. It was eliciting a lot more joy inside of me I had never experienced. My experience of my universe changed so much so that when I was like, "When I listen to the radio and I hear the music, " remember telling a friend, "It moves me. And I never felt that before." It was pretty euphoric in the initial phases. So, I'm just curious if you experienced that?

Geoff: I mean I think after fasting and being conscious about measuring ketos, the initial euphoria tapered off. But, we've been experimenting with exogenous ketones and elevating that. That sudden shift of being at zero to 4.0, 5.0, you can definitely feel like a big delta there.

Priyanka: Yeah, for sure. I know what you mean. When I've tried exogenous ketones, it does give you some sort of boost. But, it could be the cafeine in that. I'm also a really big fan of caffeine.

Geoff: Well, blinded from the caffeine. We should talk offline, that's an active R&D area for us.

Priyanka: Oh, I see. Interesting.

Geoff: So, we can talk offline about that.

Priyanka: For sure.

Geoff: Obviously don't conflate it with the caffeine. That's just BS, right? There's different classes, I think we've talked with other folks about it, but there's like MCT oil, other precursors. That's one class. There's ketone salts, then ketone esters that are emerging in terms of R&D, originally designed for military use. There's this interesting emerging technology that may be able to bring this to scale in a form that's available for everyone soon.

Priyanka: Yeah, very interesting. Very exciting kind of field. Who knows? As a physician kind of fighting the battle on the frontline I'm still just waiting for the American Diabetes Association Guidelines to change, or the AHA to adapt.

Geoff: What do you think are the systemic blockers? It just seems that this is working in clinics. Real doctors, real patients, are seeing real results. Existing status quo is not even great, it's arguably failing, diabetes, obesity rates are up into the right. It just seems that like one plus one is not adding up to, "Let's evolve some of the principles that are being distributed as gold standard.

Priyanka: I completely agree with you. Number one issue is lack of education about basic macronutrients metabolism in medical schools right now.

Geoff: I hear that you get like four hours of lecture on nutrition.

Priyanka: I had an hour. I had one hour-

Geoff: Over four years of medical school?

Priyanka: Yeah. I remember one hour and I remember being like, "That's it?" I had three days of statin lectures, you know what I mean?

Geoff: That's crazy. So, they teach you about using pharmaceuticals not food?

Priyanka: Big time. So, I remember being really disappointed about that as a med student. A lot of physicians are just not educated about this. We're in the dark.

Geoff: It's weird. Because I think five years ago I would have been like, "You guys are just crazy, hippie, alternative folks." After just actually reading this stuff, and you talk to doctors, and in a lot of ways a very well read layman is smarter than ... not all doctors, but a lot of doctors that just haven't been looking at this since college biochemistry.

Priyanka: Exactly.

Geoff: It's like the authority on this pillar is not as crisp and clear as you might have thought.

Priyanka: I know. I don't know if you've interviewed Ivor Cummins yet? But, you gotta. He's one of the most well read people about the science behind this, and he's an engineer, he's not even a physician. Sometimes I have to remind myself that he's not a physician because-

Geoff: He's up to speed.

Priyanka: I'm having conversations with him that are physician level conversations, and then at the tend he's like, "No, I'm just an engineer." Who's extremely well read. You should totally interview him if you have a chance.

Geoff: Good. Engineers talking about medicine? Great.

Priyanka: He's awesome.

Geoff: I'm not an engineer, but I tried it as well.

Priyanka: He's from Ireland, he's so funny, he's a great interview. So, yeah, it wasn't until I re-educated myself, re-taught myself nutrition metabolism, that I realized what was going on. For any physicians listening I strongly recommend getting board certified by The American Board of Obesity Medicine, or becoming a member of the ABOM because they taught me a lot about nutri metabolism. Eric Westman I think is the president now of the ABOM. They kind of just present the data, they're not preaching one diet, but you can make the conclusions yourself based off of what they teach you. They definitely helped me learn the building blocks. Then I think there's more credibility if you're board certified in obesity medicine to implement ketogenic diets. You can get very comfortable learning about that. That's one way that I think we can make a difference. Another thing is at my clinical practice I do teach medical students. It's my way of trying to at least initiate change.

Geoff: In San Francisco?

Priyanka: In San Francisco, yeah. It's funny because the med students work with me they know nothing about insulin, they don't even know how to count carbohydrates, you know what I mean? They've been taught nothing.

Geoff: They've been taught to prescribe drugs.

Priyanka: Yeah.

Geoff: And that's how you get reimbursed by the insurance company. You know a lot of the incentives practitioners are like, "Hey, prescribe drugs, get paid." Insurance is not giving you money for taking people off meds, right?

Priyanka: Exactly.

Geoff: It's this weird incentive system.

Priyanka: Yeah, it's very challenging. I think teaching our youth, teaching early medical students, educating physicians, I think there should be a law in the state of California that if you're gonna practice medicine in California you need to know some basics of nutrition. You need to know about nutritional ketosis, you need to know that the brain can run on ketones, you need to know that carbohydrates are not a necessary nutrient, that the body can create it, that there's other important nutrients.

Geoff: Interesting. When I talk to people, if they even know what ketones are they're like, "Are ketones bad? Because my uncle has Type I Diabetes and ketones are really, really bad." It's like, "Okay, lets zoom back. Ketones are actually produced as a reaction to your body not being able to use glucose. It's a protective way to fuel yourself."

Priyanka: It's really funny, because even before I learned about this officially like back in college, as a vegetarian I did figure out that when you eat cakes and breads you gain weight pretty quickly. When you're eating potatoes all the time, you put on weight. I sort of was like, "I shouldn't be doing that. Maybe I shouldn't be eating those white foods," or whatever, those flour-based foods. Maybe in a way I was feeling my little, low-carb ish, but I didn't put it together until I actually went low carb. There were signs all along, and then eventually I found where I was supposed to be.

Geoff: Then, you think that ADA, HA turn around in terms of being just, "Okay, let's step ..." what do you think are the big road blocks there? If you could just project forward a little bit?

Priyanka: That's a really good question. I mean, there's so-

Geoff: Sounds like a lot of the research is coming down the pipeline. I know a lot of different groups, it sounds like you're also working on research that is showing, "Hey, like this is working."

Priyanka: Yeah. For example, the trial I'm involved in. We're hoping that after we show those results it'll lead to more studies and then once you publish enough data that's eventually what can lead to changing the guidelines. If enough physicians learn about nutrition, eventually the guidelines will change, and once the guidelines change all physicians will change their practice. The thing about most physicians is that they're risk averse.

Geoff: It makes sense, too.

Priyanka: They want to play safe.

Geoff: Which is also the right thing to do because you're playing with people's lives, let's be conservative. But what is conservative? It's not necessarily the actual best science, best practice. It's just like where that tension is.

Priyanka: Yeah, we're playing with people's lives. From my perspective, the moment I learned about the science behind low carb diets I felt an ethical obligation to implement it in order to save people's lives. You know what I mean? Personally I lost my grandmother to severe complications of diabetes. She had vascular dementia, it was a long, and prolonged kind of process. It was very painful to see. I've lost one of my own to the fight against diabetes, and I'm not gonna lose more people. My skin's in the game. It's something I feel very strongly about. I can't wait for the ADA to change their guidelines while people are suffering. It's not an option for me. I have to do what I feel is right.

Geoff: Yeah. It's also working for your patients.

Priyanka: And it's working, yeah.

Geoff: One thing I've always found really interesting where nutrition is not being taught, but if you look at Hippocrates, he was the one that defined "Do no harm," but he also said "medicine is food, food is medicine."

Priyanka: "Let food be thy medicine."

Geoff: Which actually makes sense from a systems perspective because if we're just looking all input, all pharmaceuticals, food, supplements, whatever, at just inputs into the digestive system, what is the most common, most ubiquitous input into our system? It's the food. We're constantly manipulating ourselves with our food. If we are just saying, "Hey, as doctors don't even talk about nutrition, don't even talk about food. Let's only talk about drugs." You're very much focused on a very narrow percentage of what is being input into the human system. I think it's not a full practice if we're just focused on a small slice of what humans are doing.

Priyanka: For sure. You know what's crazy? A lot of my patients, unfortunately get really surprised when I'm sitting and going through so much nutrition education with them.

Geoff: Because I think people are trained to be like, "Drug. Pill. Done." Priyanka: Yeah, it's really sad if you think about it. Like the fact that the are surprised, or they're extra appreciative.

Geoff: I feel like there's also a sense of, "Oh, you're going to like, Woo-Woo Land." Like you're talking about hippie stuff. It's like, "Wait, we're not even talking about spiritual, weird, yoga stuff. This is actual biology." I think it's this weird tensions. You start talking about diets, "Oh, are you going to be talking about some weird diet fad to me now?" It's like, "No. This is actually biochemistry."

Priyanka: I know.

Geoff: We gotta change that perception.

Priyanka: I know, I have to remind myself that most physicians don't know how to counsel their patients about what they should be eating, and to me it's like thank God I learned about this. Because I would feel like a fraud. How can you tell people how to live? What is life? Eating, sleeping, fucking. Well, I don't know if I can even say that. You can bleep that out.

Geoff: Hey, it's a fact of life.

Priyanka: Like socializing, right? We, as physicians, need to know how to counsel on that. Medicine should be the last resort, not the first resort. Obviously if there's a medical issue, like if you're sick with pneumonia and you need antibiotics, you need to take the antibiotics. If your bone breaks, you need to get it fixed. You know what I'm saying? Obviously practice smart medicine but then know the fundamentals of health and life.

Geoff: Absolutely. I think with the decentralization of information, if we look at the internet and computing decentralizing computing power, like IBM used to just have mainframes, now everyone has a supercomputer in their pocket. You see crypto currency where it used to only be banks, and governments having financial control, everyone has a note that can run bitcoin. I see a lot of the bio-hacking community as a decentralization of healthcare knowledge, where hopefully more and more people can understand and implement with the smart counsel, with the right doctors, implement and manage themselves better.

Priyanka: Yeah, it's crazy what's in those Reddit forums. Not just for keto stuff but there are like deep threads of any topic. If you're having marital problems, or if you're trying to raise a child, you know what I mean? Huge, deep conversations on Reddit, and a lot of people depend on these things. I don't know what that says abut our society that we're not able to have frank face-to-face conversations about these issues, we have to do it in privacy. I don't know, maybe people are more comfortable sharing knowing that their identity is completely gone, probably. But we as a society are still fairly closed off. I don't know why that is. I don't know if it's an American thing of if it's a thing across the world? I'm not sure. There's so many branches to that. We could do a separate podcast about that.

Geoff: We should definitely do a separate conversation about that. What are some of the exciting projects you're working on? It sounds like you have a clinical trial going on. How do folks find you if they listen, they're inspired by your practice? What are the shout-outs here?

Priyanka: You can hit me up on Twitter, it's WaliPriyanka, W-A-L-I-P-R-I-Y-A-N-K-A. That's probably the best way to reach me.

Geoff: Cool. Just to wrap up here. How about your comedy practice? I think we should get a snapshot of that, and where we could see your next show and all of that.

Priyanka: Yeah, for sure. I perform in and around the Bay Area pretty frequently. I run a monthly free show in San Francisco at Blondie's Bar in the Mission. It's every fourth Monday of the month, it's free, it's at 8 pm. You should come. It's recurring, it's every fourth Monday of the month.

Geoff: Cool. Yeah, let's blast that information out. As always find us on SoundCloud, but hopefully that service stays live. But, if not, definitely Google Play, Apple iTunes, and YouTube. Thanks so much. See you guys next time. Cheers.

Priyanka: Thank you!

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