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January 27, 2020

Heart health with Dr. Jignesh Shah

At some point in our lives, we're all going to deal with heart disease in one way or another. In his book, Hearth Health, Dr. Jignesh Shah explains the various tests and treatments and when they're the right thing to do. 

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Allan: 01:00 Dr. Shah, welcome to 40+ Fitness.

Dr. Shah: 01:04 Thank you. Thank you for having me on the show.

Allan: 01:06 Now I really enjoyed reading your book, the book we're going to talk about today, Heart Health: a Guide to the Tests and Treatments You Really Need. Part of the reason is, you know, being in my fifties, this is kind of the time when a lot of the conditions that have us thinking about our heart start popping up, you know, heart attacks, and all the other things that can go wrong with your heart, stokes and things like that. We're reaching that age where we're seeing it happened to our friends and family that were right around this age. And in some cases people lost their parents around this age. So we start to think about, well, how healthy am I? You know, you would just think, well, I'll just go in and get these tests done every once in a while and then I'll know I'm good. But that isn't always the case.

Dr. Shah: 01:53 Absolutely. And that is one of the key points of the book that just because we get a test done and the test says you're fine, doesn't necessarily mean that nothing will go wrong. We have progressed quite a lot in that understanding of heart diseases. However, there are things that we can predict and things that we cannot and even after a normal test, people can have problems. And on the other side I would say just because you have a normal test doesn't mean that you are looking at an impending doom and gloom. You have a lot more control, you have lots more time and you've got to use it effectively to gather all the information before reacting to it.

Allan: 02:49 Yeah. I think that's really kind of where that when you start talking about heart disease and particularly when it's happening in the moment, it is really hard to kind of take that step back and think about it objective. Because everybody just knows when the last beat of your heart is the last beat maybe. And so people tend to want to fix it now versus taking that step back and thinking about it. And that's what's really cool about the book. As you had stories in there of individuals that were, we're going through different things and then different protocols were promoted and they either did it or they didn't. But some of them were rushed into decisions and some, you know, had the wherewithal to get the second opinion. So if I go into the doctor and the doctor tells me there's some problems and they want to do a procedure, it could be, you know, putting in a stent or do even a bypass, we should get a second opinion. Right.

Dr. Shah: 03:45 So you started off really good you said you go into a doctor's office and that is a critical thing to remember. You went walking into the doctor's office, that's a different scenario and he pointed out to be a good place that you have enough time to get a second opinion. Now if you went into the emergency with chest pain and the EKG show or showed that you have, you're having an active heart attack, that is not a time for us. So that's the book tries to give you the new one's version of it, but you're absolutely right. You go to the doctor's office, tell them, you know, I've been having chest pain when I walk but I'm under a lot of stress and the doctor says, let's go ahead and do a stress test it's a noninvasive test. They're not going to poke inside your body. They're not going to put gas.

Dr. Shah: 04:49 Very good test to start. However, even in this situation, we're trying to get a second opinion and slow down the crane. In some cases, you know, I have known 40-year-olds who have been running five, seven miles a day, no problems at all, and then they started a different exercise and now they're having chesting pain the rest to a stress test and that patient the same stress test may not be necessary. However, somebody who does not exercise that much and starts exercising and starts noticing chest pain with exercise stress test may be necessary so in either case you have enough time to get a second opinion.

Allan: 05:38 Yeah. One of the things I think that was was really important as I started going through the book and you stress this time and time again is if, if a procedure is recommended, you really want, you want one or two things to happen as a result of that procedure. You either want to know that because of this procedure I'm going to live or and or that I'm going to have a better quality of life. Can you talk a little bit about that?

Dr. Shah: 06:03 Yes. Thank you for giving me these two very critical things. As a doctor, there are only two things that we can do for you. We can either prolong your life or make the quality of life of your life better. So no matter how bad the pictures are how fabulous the technology is. As a patient, you really have to know does it need one of these two end goods live longer or live better? Then so if you went into the doctor for what I would call a well baby checkup, annual physical or a wellness check, meaning thereby you do not have any symptoms, any tests that is being recommended you really have to ask, is this going to make me live longer? Because remember, if you do not have symptoms so the patient can, the physician cannot make the quality of your life better, but if we can improve the quantity of your life, meaning that they are longevity, then you don't want to undergo that test.

Dr. Shah: 07:18 That test is not going to make a difference. You really have to question, no matter how fabulous the technology is, how convincing the logic is. If you do this, then this happens, then this happens and this happened. All of that becomes more and more farfetched at the bottom of the day. You want to know does this make me live longer and if you are having symptoms, will this take away my symptoms? Is it likely, particularly my symptoms and only then you want to undergo that and you know, I would say even with that, you do want to ask the physician is there a simpler way to accomplish the same thing and you would be surprised how often a more simpler approach can sometimes accomplish exactly the same thing. We know from studies of the studies now that in majority of the cases, medications accomplish exactly the same as a bypass surgery with medication. You know, so you always will, ask the physician, is there a simpler way to accomplish the same group?

Allan: 08:28 Right. So, you know, being older, you know, I do go in for wellness checks and if my doctor had recommended to me, Hey, you know, you're over 50 now, let's, let's do a stress test. And no, I haven't had any symptoms. I haven't had any problems. I only had one incident where I thought I had a problem, but it turned out to be basically my sodium got too low and I went into the emergency room with chest pains. And that was really because I had had an episode of a seizure. And then during that seizure kind of strained my chest. And so to me it was, you know, I was feeling really bad because my sodium was low and as soon as I went in and you say the word chest pains, it leads to a whole, a whole set of protocols.

Allan: 09:11 You're taken straight to the back. You're given a nitroglycerin and they're putting you on a drip there. They're checking your heart rate. They've got you on a machine like that. And so it turned out it was just, it was dehydration and low sodium combined was what mine was. Now had they told me after that you probably should go do a stress test. I wouldn't have known any different. I would just said, okay, well my doctor said I need to do a stress test. So I think it's important to know that, you know, do you have symptoms that are okay? There are some of the heart attack symptoms, but if I have to agree, okay. The doctor says, okay, you should go get a stress test. And I agree. Tell me about what, what does a stress test entail? You know, what does it like and what's it going to tell us in the end?

Dr. Shah: 09:52 Right. So a stress test is performed to increase the activity of the heart, so as to increase the oxygen requirement of the heart itself. And under that stressful situation, if the heart muscles which are now requiring increased oxygenation do not hold up, then it indicates to us that there are some blockages to the blood flow. To the heart itself and the way to accomplish that is ideally to walk the patient on the treadmill, well connected to the EKG machine and look at how the EKG or ECG changes take place. And if there are some changes then that is concerning. However, if the patient is able to walk 10, 11 minutes and has no chest pain whatsoever, the EKG does not show any abnormality. Then they know that their heart is able to work under this stressful situation. Beach indirectly tells us that there are no blockages.

Dr. Shah: 11:05 So the idea of stress test is where you would maybe walk on the treadmill with EKG connected to you and somebody's observing the EKG or blood pressure and your heart rate. Sometimes there are additional testing added on to it where you get injected with radio active dye which is injected when you are at the peak of your exercise and then you're put under a camera where the emission from the radioactive dye is picked up and it hurts us. Understand if there are parts of the heart that are not receiving blood supply. Once again, that indirectly tells us that may be blockages in the heart artery. That's the typical stress that is performed and it is performed to figure out if there is a chance that you have blockages in the heart artery.

Allan: 12:02 A lot of times if someone's had an issue in the past or a doctor just feels uncomfortable and you're going to go in for a surgery for something entirely unrelated, they may make you required once you to do a stress test. Should you try to get a second opinion, should you try to talk them out of it if you've had no symptoms or is this something that maybe you just want to go ahead and do?

Dr. Shah: 12:21 No, I think I'm American college of cardiology and American heart association is very clear about the fact that in rare high-risk surgery you need a cardiac clearance and a stress test prior to that. Outside of those rare surgeries for 90 to 95% of surgeries, you do not need a stress test, to undergo orthopedic surgery or a back surgery or what have you. And so for majority of the cases you do not need a stress test. And I would strongly urge you to get a second opinion before you undergo that stress test because the chances of that stress test veering you away from what you really require, which is that surgery, it will just point to a different direction. And as you've read in the book, it will lead you down a path that you will not want to go. And that is why American college of cardiology is very clear about the fact that majority, I mean the overwhelming majority, 90 to 95% of surgeries do not require a stress test prior to undergoing the surgery.

Allan: 13:37 Yeah. You had a story in the book where a woman had torn a ligament in her knee and as a result, she wasn't able to be active like she wanted to be. And obviously if you're not active, you a trophy and, and so she couldn't, she couldn't walk with her friends. So she was missing the social aspects and the fitness aspects of it because she failed a stress test.

Allan: 13:58 Then they were like, okay, well, you know, I think she went on for other procedures and, but she had to wait a year before she could come get that surgery. That's, you know, a year of, of inactivity. Scary. And so that was definitely not going to extend her life or improve the quality of her life. It was really of cause the exact opposite.

Dr. Shah: 14:17 Exactly. I mean, she been for a stress test that was not acquired then she had, she was asked to undergo this cardiac catheterization and she had complications from that. And from that point forward it just went into this cascade of negative events where she was not able to get surgery that she required for almost a year and had she not gone through stress test like it is recommended by the American college of cardiology. She would have gotten the ligament surgery and went on to be active back again, which would have done more good than all this additional testing.

Allan: 15:01 Yeah, so if I go through as far as stress test and the doctor finds something abnormal and they say, okay, we need to do this next procedure. As the cardiac catheterization you spoke about, can you talk about what that is and how they do it and what we can find out from it?

Dr. Shah: 15:15 Yes. A catherization test is an invasive procedure, meaning that the doctor is going to get inside the body, they will number the area around the groin where one of the major artery is, sometimes they can use the major artery in the arm. And once they get access into the artery, they put a catheter, a small, tiny long plastic tube that goes into the heart artery and they inject dye into it by taking pictures of the flow of the dye under the camera. And by getting several pictures we understand where the blockages in the heart arteries, based on where the blockages are we can further prescribe the right type of medicine or discuss the possibility of stints or discuss the possibility by-pass surgery, depending on the pump or not the blockages it tells us a lot about the blockages in the heart.

Allan: 16:25 And again, it's one of the things I really like about your book is after you've had that, you know, that initial test or you know, then the second follow up the catheterization test, your book goes on to say, okay, here are some of the options that you might be presented. There's medication, sometimes there's bypass with medication and it gives you the questions to ask your doctor. So as you're facing these things, I think your book's an awesome resource for someone because it answers a lot of questions very, very easily. And then you can ask your doctor the right questions, you can get your second opinions and you can make sure you're doing the right thing to increase your longevity and quality of life.

Dr. Shah: 17:02 Absolutely. And thank you for bringing that up because on the web, what I notice is that there are a lot of generic questions which may or may not apply to your specific situation. So I have wanted to equip my readers with very specific questions for that particular procedure, which is pertinent so that the patient in the position exists, that willing to be an active process. You are willing to be part of the healthcare team and not just a passive sit here.

Allan: 17:36 And let's hope, again that's your physician is a, is a main role to you having that and being a part of that team. Cause if that physician is not you, you might need to find that another physician.

Dr. Shah: 17:47 Absolutely. I agree with you completely.

Allan: 17:49 Now you, you, you kind of mentioned Dr. Google, you know, people love to go on dr Google and self-diagnose. We also love, love, love to wear these tools to measure everything. You know, so the Apple watch and some of the other things that are out there, you can know how well you sleep. You can know how many steps you take in a day. You can know your heart rate every single day, including, now I guess Apple watch does an EKG for you. If someone has one of these watches on and they start noticing and an abnormal rhythm or you know, something going on and their watch is kind of, is that something they just definitely need to walk into the doctor and start having some conversations or is it something that they should just sorta say, okay, I get it. I don't have any other symptoms but the watch is telling me there's something amiss.

Dr. Shah: 18:38 Yes. So there are a few aspects to it. I will mention. So if you are having symptoms and it correlates with the EKG section or the heart rate section of your wearable device showing abnormality, if those two concur, then there is good reason to go to the doctor and get checked out. Secondly, there is a condition called atrial fibrillation. Unfortunately, as we age, a lot of us become familiar with that term atrial fibrillation. And what we know is that people who have atrial fibrillation have an increased risk of stroke. And so if the Apple watch is talking about the possibility of atrial fibrillation based on the EKG, then you do need to get checked by a physician. Maybe get another monitoring gadget that they can look at and figure out if it is indeed interpolation. And if so, how does it need to be treated because of the increased risk of stroke.

Dr. Shah: 19:54 There are things that we can do to decrease your risk of stroke. So from that standpoint of is critical. However, the other aspect I would also say is that people don't need, to me these variable devices, the source of their anxiety. Please know that nature has given you one of the best gadgets to assess how your body's feeling and that is your own self, your own understanding of your body. If you notice that every day you've been able to walk five months and for the past two weeks at two miles, you're just getting by tells you're huffing and puffing. That is enough reason. That is more of reason to be concerned well and beyond what the Apple watch tells you. I think we understand some of the technology, we understand some aspects of how the heart functions and how our body functions, but it is all in combination.

Dr. Shah: 21:05 Just the heart rate by itself doesn't tell you the complete story. Just the EKG by itself doesn't tell you the story. That is where physicians can put things together for you and say, is this critical or is this not critical to be addressed. And sometimes the treatment can be worse than the disease itself. And I want the listeners and the readers to be open to a conversation that isn't something that is so bad that the treatment will make it better. Is if six or one and a half dozen of another well was treatment as well.

Allan: 21:46 You know another interesting thing that comes out of these wearables, it's a conversation I've had with one of my clients. He has a resting heart rate in the low 50s and I have a resting heart rate in the high 70s. And so, you know, if we go and we look at that formula where our bodies, and our watches are saying, you know, stay in this zone. He can't, he can't get to the zone. He can go 100%. His perceived effort level is 100% and his heart rate just will not get up to pass one 41 50. It just, just won't mine, I could get my heart rate up pretty quickly, but I also don't feel full exertion at 177 or 180. I can actually exert past that for a sustained period of time. And, and I try to, you know, I try to explain to folks, it's like, okay, this is a formula that works for a lot of people, but not everybody. So can you talk about where this max heart rate thing came from and how it kind of blew up into this,fitness craze of people thinking that they have to be in this magical zone all the time?

Dr. Shah: 22:48 Absolutely. so that is a very interesting story. You know, in the 1930s and 40s, doctors have promoted this idea that any kind of activity is bad for your heart. Patients with heart condition used to be told you need to rest. You can't exert yourself too much. You can't have too much stress. You can't argue with people and so on. And then as time went on in the 50s, the people started realizing that people are actually doing better when they're exercising. So the world promotion of exercise came into be a jogging was promoted and so on. And at that point in time, burning question in the physician community and cardiologist community specifically was what other heart patients who have had surgery for the heart condition, what kind of exercise can be recommend safely. So that was a burning question that was brought up time and time again.

Dr. Shah: 23:54 And the health services department knew that they would be asked this question during a certain meeting. And so at that point in time, what they did was the junior colleague was asked to collect some data regarding that. So he took into consideration 10 papers written about cardiac patients, young heart patients who had undergone heart surgery and what was the safe level of exercise and when they assessed this data in a very preliminary manner. They said, you know, there is this easy formula that we can come up with. It is 220 minus the age,based on what they observed. And so they went and spoke at the conference and when they were as expected as how much exercise can somebody do. Yeah. After having had heart surgery after having had heart disease, they said it seems that the safe level is to get to a heart rate of 220 minus age.

Dr. Shah: 25:00 Now even the people who were recommending this knew that even among the heart patients, people who had undergone heart surgery, this was a wide range. This was just a general guidance given. Just like what is an average human height. And we would say in the US it is 5'9″ or 5'8″. That doesn't mean that if I'm 5'7″ I need to get looked up about it. We immediately recognize that. And so then the experts assume that this would be recognized that this is not hard. And it's true. And this was the data only for patients who had a hand be at a young age. Father had significant heart disease. But as it happens, numbers are attractive. You know? So it just took a life of its own. So people put up posters in the fitness centers and gymnasiums and so on.

Dr. Shah: 26:07 And then there was wearable device made and show enough that industry has just exploded. So the drum beats of measurement and quantifying has just taken on a life of its own. Though this was never meant specifically for, this was never meant for the general population. So it is good to have a general guidance. However, do not let yourself be restricted just because of this. As I mentioned, nature has given us a much parameter, which is how do you feel? Are you feeling alright? Then go for it. Exert yourself a little more. If you're not feeling alright, it doesn't matter at what heart rate you are. That's body's way, nature's way of telling you that maybe there's something amiss and you need to stop.

Allan: 27:01 I define wellness as being the healthiest fittest and happiest you can be. What are three strategies or tactics to get and stay, well?

Dr. Shah: 27:11 Number one I would say look at home care more than healthcare to make you healthier. And what I mean by that is regular exercise, quitting smoking, and eating a healthy diet. That would be the first and foremost thing that you can do at home to get the most bang for the buck. Now step number two would be to get a good assessment and control of your blood pressure and if you're a diabetic, of your blood sugar. That would be my step two. And step three would be to practice optimism, mindfulness and graditude. And I see all these three based on solid research evidence, which has shown that all these three things, to give you a much healthier heart, much healthier heart than otherwise. There has been tremendous research on optimism, gratitude and mindfulness and then to live 5 to 10 years longer and happier life compared to the pessimists. So I would strongly recommend your audience to consider these home care steps before approaching the healthcare system.

Allan: 28:52 Those, those were really cool. Thank you for that. If someone wanted to learn more about you, learn more about the book, Heart Health: a guide to the tests and treatments you really need, where would you like for me to send them?

Dr. Shah: 29:04 So my book is available anywhere books are sold. Amazon.Com, Barnes and Noble, Booka a million, etc. If you want to learn more about heart and all these tests and treatments, want to explore it a little more. Want to know a little bit more about me or want to communicate with me. I have a website called JShahmd.com where I have lot of information about heart conditions, pictures with videos and even if you're being advised for procedure, you're we have videos and written material that is not difficult to understand and so it could be worth looking.

Allan: 29:57 Okay, this is episode 418 so you can go to 40plusfitnesspodcast.com/418 and I'll be sure to have those links there. So Dr. Shaw, thank you so much for being a part of 40+ Fitness.

Dr. Shah: 30:09 Thank you very much for having me. Really appreciate it.

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January 20, 2020

Medical tourism with Janet Bristeir

More and more people are traveling abroad to get treatments and surgeries that are much cheaper. Is medical tourism right for you? On episode 417 of the 40+ Fitness Podcast, we meet Janet Bristeir and discuss her book, Medical Tourism: Surgery for Sale.

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Allan: 00:59 Janet, welcome to 40+ Fitness.

Janet: 01:01 Hi Allan. Thank you very much for inviting me on your show.

New Speaker: 01:04 Now your book Medical Tourism is something that's been kind of top of mind for me lately because I get a lot of questions about why I moved to Panama. But before I get into that, I have to get into the subtitle, which is Surgery For Sale, How to have surgery abroad without it costing you your life. That was brilliant. It opened some eyes and I like that because we moved to Panama to save money in healthcare. And a lot of people ask why and how that works and if they have to move to a country to get those same benefits. And my short answer is no. But there's a lot of things to consider before you just decided to get on an airplane and go get some surgery.

Janet: 01:46 Definitely. And basically medical tourism is when people are thinking about traveling internationally to purchase medical care. And we're usually talking about surgery. So, and the thing with that subtitle of my book is that most information people see about medical tourism is the headline. A person comes back from surgery abroad and dies of something. So that's that information there.

Allan: 02:15 I remember reading about this decades ago when it was, I guess South Africa was kind of marketing themselves as the plastic surgery capital of the world and people were flying into South Africa. They would get their plastic surgery done and granted they needed about a week or so for recovery. So they're out doing African safaris as far as any of their friends or family or maybe even doctor knew, they basically just went on a Safari and came back two weeks later looking a lot happier, tanner and maybe with a smaller this or a bigger that. Yeah.

Allan: 02:56 So let's talk about medical tourism. Cause I'm really what I would call a medical tourist. I'm a medical resident, not a medical resident in the state of actually working at a hospital. But we traveled to Panama, we were looking at our, our health insurance, me being self employed and just the overall cost structure of what was going on with the rates, everything going up every single year, double digits in the United States. And you know, I was saying, well before I'm eligible for Medicare or any assistance whatsoever, I'm going to get costed out of this model and there's just no way I can afford medical insurance itself. Not to mention medical costs under my new profile of living. And so we looked around and Panama was one of those locations where medical care is high quality, it's low cost. And I can, I can tell some anecdotal stories both that we've experienced and others have experienced here that really are kind of our model now for healthcare. But when we're talking about medical tourism, we're actually talking about traveling to another country for the purpose of having a medical procedure done. Like you said, usually surgery and then heading back home typically to finish out the recovery there.

Janet: 04:06 Very true. Yeah. And it's usually because people are frustrated with the wait times for surgery in their own country. You know, it's like, and the wait times, they have serious consequences. You've got the increased pain, suffering, mental anguish, and sometimes poor medical outcomes because the longer you wait for something, there's the potential of that disease or illness turning into something that's irreversible and you've got a permanent disability.

Allan: 04:33 I had a colleague that was working with me and he was having shoulder issues and he was like, he was in a lot of pain and they gave him some pain pills and they helped with the pain, but he couldn't drive his vehicle and he couldn't focus on work. And so he went back to his doctor and his doctor's like, well, it's a six month wait for this surgery. And he was just at wit's end and he's like, I can't not work for six months. And while I don't know about the medical leave and how that actually works in Canada, in the United States, it's 12 weeks. And so he, you know, if he said he had to be off work on a doctor's note, so he can't work for 12 weeks, that's fine. If he has the time off and can afford to be away from the office that long, most people can't.

Allan: 05:20 So he was at wit's end of, fortunately being in Canada, he was able to fly from Calgary to Toronto to find a doctor that could do the in a place that could, they could do the surgery sooner. So we didn't have to leave. He was actually looking outside of Canada to have that procedure done because he just knew there was no way he could bear the pain and there was no way that he could do the pain meds and keep his job. And that was unfortunate. But it is just kind of a reality of healthcare today.

Janet: 05:49 Well that's true. I mean, and that's the thing, you know, people have to lose their wages while they're waiting for the treatment. And so the economic cost just adds to that stress and it's terrible. And just for some data in 2018 Canadians expected to wait four weeks for a CT scan or 10 weeks for an MRI or maybe four weeks for an ultrasound. And in that same data set in 2018, they were talking about 30% of patients who required hip or knee surgery or cataract surgery didn't have the procedure done within the recommended wait times. And so what you find is that people that have the time and the financial resources, they don't want to wait. They want to get ahead of the game and they want to go and they, that's why they're looking internationally for these things.

Allan: 06:38 And then in the United States, I think the base story is that well we have the affordable care act and I don't want to get into the whole politics of, of that. Healthcare is not really affordable. We paid much more for the same procedures, for the same medicines than we would elsewhere. So the opportunities for us to save money by traveling is pretty significant.

Janet: 07:01 Yeah, it can be very much. And the other thing, you know, what we find here in Canada, you know, it's a very diverse population and sometimes people would incorporate going back to their home country and staying with relatives to have surgery or procedures. So they, they will travel abroad, they'll, they know that that country, they could get their hip surgery or cardiac surgery or whatever much more timely and they've got the family support there that they need for recovery.

Allan: 07:31 And I think that's key. That's what some of the things that you brought up in the book because it was not a direction my thought process went naturally being a resident and having access to lower-cost healthcare, it wasn't something that I thought about, but obviously one I would not take my wife or myself to a clinic that I didn't feel was capable of taking care of us. And this, one of the things I can say is in doing research on this some of the things I found is like here in Panama, if you're concerned about the quality of care, one of the hospitals that I took my wife to here to have some work done is basically a Cleveland clinic. And people from the United States might not know that name, but it's basically one of the top medical establishments in the entire United States. They have an outlet in Panama. The doctors there are the same caliber. In fact, our doctor had worked in the United States including the U S military for over 31 years. And so the quality is there. Obviously, you know, our, our hospital here on our little Island, not necessarily all of that, but if we need something, we know where to go and it's not that difficult or time crunch for us to get to high quality care. And that's going to be the case in a lot of countries, particularly the countries that are really investing in medical tourism.

Janet: 08:48 Yeah. And when you're looking at the different facilities, you know, one of the things that we're concerned about is that if someone is considering being a medical tourist, is that they actually get informed consent about the medical procedures that they're going to receive abroad. Because what you find with most of these sources of information is that it's a marketing focus and they don't actually provide enough insights into the risks involved, not just with the surgery but with the travel and things. And so that's another factor to consider when you're looking at locations and doctors and things like that.

Allan: 09:26 And I want to go down that line because you, you mentioned a lot of really important things in the book. The like I said, kind of being a resident didn't really, they didn't initially think about was what if you have a doctrine in United States and that doctor says, okay, I'm willing to do the surgery in six weeks. That's when my next availability is and you find that you can go to say Mexico and enjoy a week there and have the surgery done come back. Is your doctor actually going to want to do post-care on a surgery he or she didn't do.

Janet: 09:59 Usually, no. You have to have a very good relationship with your doctor, whether it's your GP or your specialist before you go away and there's various reasons people are told they can't have surgery as well. So it might just not be a factor to do with the wait lists. Sometimes people are told that they're not considered for surgery because they have other, what we call co-morbidities, wherever other health concerns where a surgery wouldn't be good for them at that particular time. And so it's not necessarily just the doctor said you can't have this, it's you can't have this because it would affect this, this and this and this. So then if someone jumps and goes abroad for surgery and has surgery when they come back, these things that have been a concern in this country before they go, you know, might be exacerbated. So that's the other thing to consider. But definitely having that followup care arranged before you go, whether it's with your doctor, with a specialist, a physiotherapist, you might need ongoing counseling. So you're gone for bariatric surgery. You definitely need a lot of support when you come home from like a dietician or a forum, some kind of chat group where you will get that support because it's a huge lifestyle change.

Allan: 11:22 Yeah, I think a lot of people, if you're going in for something fairly simple, which most of the time that's not where you're going to get your bang for the buck. That's worth buying an airline ticket. Most of these are going to be surgeries and in many cases a pretty major surgeries like bariatric surgery or hip or knee replacement, something like that. Maybe even some plastic surgery, but usually again, something probably a little bit bigger. The recovery is something that's really, really important to think about. And are you going to have the family support to get you through that?

Janet: 11:52 Well, that's right because if you haven't got that psychological support, especially if we're talking about bariatric surgery, you know, if you go and have the surgery and you come back and you've got these extreme changes in diet that you have to comply with, but you've got someone in the family that's always saying, well, I've made this for you, eat this, or why don't you try that? It's defeating the object. They'll just wear you down and then it won't be successful. But if you've got people at home that are supporting you and encouraging you with the diet, with the exercise, with looking after yourself, when you come back you'll have a much better recovery and a much better outcome.

Allan: 12:30 Yeah, and another thing I got into you got into is a little bit about talking about your employer and obviously you're going to have to take time and potentially a good bit of time away from work because you've got to mix in the travel time along with the recovery time along with the surgery time. And I got to thinking we would, we would let someone off of work if they had a doctor's note and say, okay, I'm going to be out for three weeks for this surgery, but is your employer going to accept the doctor's note from a doctor in Thailand or do they think you're taking three weeks to vacation on, on FMLA, you know, and I'm on medical leave.

Janet: 13:04 Well and also do you want your work to know about it? If it is a plastic surgery or something, do you want work to know? So that's the other thing is it might be something that's very important to you, but you might not want everyone talking about it around the water jug. And the other thing is if you might have already been off work with whatever's causing you to have the surgery and then the surgery, you've had the surgery, but during your recovery you might need some kind of accommodation, reduced hours or working back into the system. And is your workplace going to be able to accommodate that?

Allan: 13:39 Yeah. Well under I know under us law there's a, there's a thing called family medical leave act, FMLA, and it specifically kind of puts the parameters of how an employer treats an employee relative to their medical care to include. Then there's HIPAA. So if you have a medical issue, you should be able to go to your HR or whoever that is that would be handling that for you and your company. Give them the basic information that they need to know along with communication with your doctor and that's supposed to be a very protected area. That information is not supposed to be circulated. So it's not water cooler stuff, but just recognizing that the law is pretty specific about, you know, coming back to your job, how long they have to hold your job open, what kind of accommodations are they required to do and which ones are they not. So working carefully with HR to understand what your rights and responsibilities are, I think is a huge consideration as you go into this.

Allan: 14:39 So someone decides, okay, I definitely want to have this procedure done. My knee is bothering me, my doctor says we're not going to do this surgery until you're 63 and that means for like, if it were me, it's like that's 10 years of constant pain in this knee. If that were the case, I don't, I don't have any problems with my knees, touch wood. But if I did and the doctor says I'm not willing to do this surgery until you're 63 and then I find a doctor or find a physio and say, okay, I'll do the followup. If you go get the surgery in Panama or Thailand or wherever, Mexico, how do I decide, because again, I just listed three countries. There's different costs, structures to those. Obviously different doctor facilities available. There's just a lot of information to kind of pour through. How, how do you decide what doctor, what location and when, how do you, how do you do that?

Janet: 15:32 Well, that's what I say. I'm think one of the first things we need to touch on here is that does someone want to organize this themselves or not? Because if someone can organize their vacation really well and they always have great places to stay and stuff like that, that's great, but if you're someone that every time you book a vacation, the hotel you get is half built when you get there and there's no taxi, you have to really consider are you going to do this yourself or are you going to get something what they call a medical tourism facilitator to organize this for you. And that we can talk about afterwards as well. There's, there's a whole other problem associated with that, but things that you want to look at is how far away is the facility and will the travel to the facility you're thinking of determined, you know, it'd be detrimental to your condition before and after surgery.

Janet: 16:22 Because if you are going to be on a flight for six, seven, eight hours, just in normal fly in, there's the chance of deep vein thrombosis, which is a clot you can get in your leg and that can cause all sorts of problems. Now if you're already having problems with joints and things like that, that long flight is going to be a problem to start with. And a long flight before you're going for surgery is definitely gonna be a problem. And then after the surgery, depending on what surgery you're having, you can't fly straight after surgery. Like if you've had gastric surgery, you can't fly within a few days because the gas that they put into your abdomen for the part of the surgery has to be completely dispersed because otherwise the pressure in the airplane can create problems. So there's things like that. How far is the facility you're looking at to travel to. And also if you're going to another country, do you speak the language?

Janet: 17:22 So if you don't speak the language, how are you gonna communicate with the staff? If they have limited English is your first language. If they have limited English, how are you going to communicate them, especially when you're stressed and you're in pain. So it's things like that. And then again looking at the facility, are the surgeon and the staff licensed to be practiced in in the country that they're practicing in? If they've got the right credentials. And is the condition and the related surgery a familiar position, or procedure for them or is it something that they are just doing for a few months just to make a bit of extra cash. And then do you have contact with the surgeon pre and post op. So it's really nice to know who's doing your surgery and lots of facilities, whether you're doing it yourself or through a medical tourism facilitator.

Janet: 18:17 You're quite often have like a Skype call or at least a phone call with your surgeon before the surgery so you can get some kind of feel for, you've got some rapport with them. And then when you're looking at the facility, you want a facility that's accredited by an international certification agencies, something like joint board, international, Canadian international standards because you want that facility to be run to the highest level as far as cleanliness, staff certification and follow up like that. And then when you've had your surgery, will you be given reports of your surgery in a language you can understand to bring back home because that is going to be really crucial to your followup care. If you go to Mexico and you have a surgery and they give you your surgical report and it's in Spanish, you know, and no one can read it. Or if it's handwritten and no one can read it, you can't get your full out care done until that's been translated and transcribed. So it's things like that that you have to consider.

Allan: 19:25 Yeah, and so it's not just location. It's cool. You can say, I want to go to South Africa and have this cosmetic procedure done and then after the recovery or during the recovery time, I'll still be able to do this safari and I'll be able to go and see the beaches and then I'll travel home with a little bit of a tan and, and the surgery done. But if your recovery is going to be much more difficult than that, you have to consider that in the whole math of all of this because it's not just a pick a doctor and go, you've got to kind of do your homework.

Janet: 19:56 I think as well, you have to dispel the fact that it is a holiday. It's not a holiday, the phrase is medical tourism. This is not a holiday. This is not a vacation. You shouldn't even plan to be looking at the country and doing it. Because I think as we touched on briefly when we were talking, if you start doing trips tourist type trips before your surgery, there's a potential for you to get some kind of acquired effect infection while you're wandering around. You might eat the local food, drink the water, you might get some kind of infection or illness and that will delay your surgery. And you also got to consider most people take a caregiver with them, a companion. And what happens if your companion goes off and does touristy things and they get sick while you're away. And that's a whole nother level of stress.

Allan: 20:48 You took me on this great trip to Panama and then you got sick and I had to look after you. I basically get to sit in a hotel room and hang out with you. I don't get to actually see anything. So yeah, I totally get that as like, Hey, come down to Panama with me. It's like, Oh no, I don't want to just sit in a hotel room with you. I could do that anywhere.

Janet: 21:11 Well, and also you have to be very careful about who you choose as your companion because this is a medical procedure. You're going to be talking about some very personal things and do you want your golfing buddy, which is great to play golf and sit in the bar afterwards and yak up a storm, but you want that person in when you're being asked about your bowel movements or things like that.

Janet: 21:34 And also do you know this person will actually function in a medical facility because there's lots of people that they're the good guy, the good woman or whatever, and they walk into a medical facility and they just close up. They are totally overwhelmed with it. They don't deal with it. And so you really need to be sure who's going with you that they can be your advocate, that they can speak up for you when you can't because we'll beyond the facility.

Allan: 22:01 We've talked about this before we got on the call and it's true. Most Americans have no desire or ever will travel outside the United States. They don't even own a passport. And so you take someone who's never been outside the country, doesn't speak the local language, and while you might be able to speak the language fluently and you gave them a medical power of attorney, when the doctor comes out there and starts speaking to them and trying to explain to them what extra thing needs to happen, are they going to be able to handle the stress of being in another country having to deal with, even if it's not a language barrier, just a pronunciation issue that's asking a lot.

Allan: 22:40 So this has to be someone that you really trust, someone you know that's going to be comfortable in not just the medical perspective, but just being out of their element. Because traveling outside the United States, if it's your first time is already pretty stressful.

Janet: 22:53 Very true.

Allan: 22:55 So you talked briefly about medical tourism facilitator, and this is a little bit more than just a travel agent. Obviously they'll do a little bit of that for you too. But their job is to kind of make this process of the looking and doing the research and understanding what's going to happen and how it's all supposed to work, that they'll do a lot of that work for you.

Janet: 23:17 Definitely. And again there's all ends of the spectrum involved in this. What you want is a well established medical facilitation company and so ideally someone that's not just linked to one facility because you want someone that's got your best interest at heart that it's not that they're just sending you somewhere cause they're on commission for it. So you want someone that when you go to them and say, look, I'm looking for knee surgery. I've been thinking about going to Panama. What can you suggest? They need to discuss with you? Well, why are you thinking of Panama is an eight-hour flight away, whereas this is other hospital that's four hours away from you. Where are we could get something similar. It's someone that's got your best interests at heart, so they're looking for the best deal and the best surgery and your best outcome. Not, okay, I'm going to put you into this hospital because I get the commission from this and from the airline, from the hospital or from the taxis, whatever.

Allan: 24:17 Yeah. And so understanding who you're working with, and one, how are they getting paid, who are they loyal to? Those are all really, really important. And again, like you said, they're experienced in doing this.

Janet: 24:30 I mean, because someone, someone can be a travel agent but they can't arrange the surgery and someone can work for the surgical facility, but they can't arrange the travel. So you want someone that's got that qualification where they can put both of these together. And there are lots of really good companies where you have the initial conversation with you, they set you up, you decide what facility you're going through and from the choices they give you, you have the conversations with the surgeon. They have, sometimes companies have someone that will go with you. So instead of you find it a companion to go, they have someone that will travel with you and be with you through the procedure and come back with you and they take care of making sure that you have all the documentation to bring back with you and that it's translated and they sometimes do followup for like six months so that they check in with you afterwards to make sure you're getting that follow up.

Allan: 25:26 Not to even mention visas and everything else because that's a whole other animal as you're traveling internationally is making sure that your, when you land, they actually let you stay. Now we talked briefly, you're in Canada, so you're under a program there with your national government, in the United States we have national, when you get to the age of 63 or 65 or 67 I forget where the age is right now that you'd be eligible for Medicare, but because it just seems like 10 years, 15 years from now, I don't even know. But one of the main reasons I came down here was because when I got my insurance quotes, it was $1,600 a month and I'm going to count it by trade. And there's a rule of 72 which basically says that if something's going up a certain amount, you can expect it to double based on multiplying that by 72 so at a 10% increase, which was conservative, I was looking at my insurance doubling every 7.2 years.

Allan: 26:25 So if my insurance doubled every 7.2 years before I was eligible for Medicare, it would quadruple. It would double and then double again or even more. And so I was looking at healthcare costs well in excess of $5,000 a month. And that's, that's not even the medical procedures, copays, percentages, anything. That's deductibles, that's just for the insurance. And I was like okay, that's, that's not sustainable. I can't just keep staying in this rat race. That's part of what I was getting out of it for. And I don't want to make my wife have to do the rat race cause she doesn't want to either. We want to live simpler lives and that was part of the choice to come to Panama.

Allan: 27:06 We were talking to a realtor here and one of the cool things he said was he broke his ankle. Not cool thing, but he went over to the mainland. It's about a 30 minute boat ride from here. He went into the clinic there, they x-rayed it, they set his ankle, he went back for two follow up visits. So he did have to ride, drive his boat over there and back a few times. I'm not difficult. Like I said, half an hour, easy boat ride. He did that and his total costs for the entire procedure, including the X rays and everything was $250. My wife had x-rays for x-rays of her knees and total costs with x-rays was $130 and now she's still having problems with the knees and she wants to go in for an MRI. The MRI is $400 so out of pocket is sustainable here. Which is part of what we love about it now, we did buy these international insurance plans. Basically it works everywhere, including United States. So if I went into the United States and had a medical procedure, I've got a $5,000 deductible, so I hope I wouldn't hit that. But if I did, I know I've got insurance for something catastrophic. So I'm buying this catastrophic plan that I wouldn't be able to by living in the United States.

Janet: 28:16 Right. And I think one, one of the things about people that are looking for surgery abroad, one of my big concerns has been is what insurance they get to cover them when they're abroad. And for six years I've tried to find places that would cover them, all the big companies and that and no one would touch it. And just a couple of weeks ago I found a company here that actually has medical tourism coverage and benefits and it's really interesting because when you talk to people, as we said earlier, most people think, Oh, I'll just get travel insurance and that's it. But that's not going to cover it. You really need something where you're saying you're going for a surgical procedure and that insurance is actually going to cover anything that might go wrong where you need to come back, whether it's you or whether it's your companion and not just flying you back but covering you for maybe six months afterwards because something could happen that you get a complication, you know, a few weeks, a few months afterwards and does that insurance still kick in and this, this coverage actually seem to do that.

Allan: 29:21 And so I think that's one of the cool things is that as medical tourism is kind of growing, these insurance programs are coming about when folks do hit Medicare age. One of the programs we can buy into here is basically medical evacuation. So if we have a heart issue or something significant and just don't want to go to Panama city for it and we want to go back to the United States and utilize Medicare for example, we can have a policy that basically says in the event I have a problem, heart attack or stroke or whatever, I can be medivaced and my spouse with me to the United States and they'll take me to Houston or Miami, whichever is the most cost effective, and then I can be admitted there and they can deal with the issues. So there are these opportunities, they're forced to use the insurance.

Allan: 30:08 And I think it's something that you do have to think about because you may say, I've got the $7,000 in the bank to go down. I got my airfare, hotel, lodging, everything covered, food and the surgery. But if you end up having an infection or a complication during the surgery and you're going to spend an extra five to seven, 10 weeks, whatever, in the hospital there, do you have that? And so insurance is something to consider as you get into this because your insurance from the United States, and probably from Canada may not cover those costs and you're out of pocket on all of those.

Janet: 30:42 Very true. Yeah.

Allan: 30:44 So if someone's thinking about this and considering this, what are some of the most critical points that they should consider as they really get into it, cause we've talked a lot about talking to your doctor, making sure your family is engaged, having someone there with you, understanding the true cost of what this is. Because it's not just how much is the procedure, but what would you say if they're going to do this, what's the most critical aspects that they should just have top of mind throughout the whole process?

Janet: 31:10 I think I would say safety and that insurance coverage I think is a very good blanket too to wrap themselves. But also that checkout the facility, talk to people that have been there if you can and people that have been there recently, not someone that was there five years ago, someone that was a last week, last month, and find out what their experience was because staff change, things change. Find out about the travel arrangements, where you're going to travel. Are you going to be staying in a hotel before your procedure? Then you're going to be in hospital. Then you're going to be in a hotel for a few days afterwards. When you're in the hotel, is there someone going to be coming to check your dressing? Are you going to have drains associated with your surgery? Someone coming to check them and take them out? Will you see the surgeon the day of the next day after your surgery? Who will be telling you when you can travel home? What physiotherapy do you need? What changes of diet? These are all the things that you have to take into consideration.

Allan: 32:10 Yeah. And, and one of the cool things, like I said, in the community here in Panama, there's these open forums, these forum groups. And so you can get out there and I'm pretty certain on Facebook and otherwise there's forums of people that are doing exactly what you're trying to do, exactly where you're trying to do it. And there are a wealth of information. The same questions get asked over and over sometimes on these forums, but we put up with it and we answer the questions. But you can search these forums. Facebook's made that a lot easier to do these days. So take some time, do that base research, get to know some people. Because what I've found is internationally people just really want to help each other out. If they've experienced something that they want to share that information and help others. So reach out. You'll find folks that have gone through exactly what you're trying to do and they'll be able to give you some really good information, really good tips and steer you away from some potential problems.

Janet: 33:00 Yeah. And I think it's also very crucial that people make sure they've got followup when they get home. That they've arranged that there is a doctor that's going to see them when they come home or a surgeon, you know that someone is going to check their dressings if they've still got them, they're going to get the physio therapy cause it's usually takes a while to get into these appointments. They need to book their physiotherapy for the followup when they come home, if they've had kind of joint things happening and they have things in place. I mean and it's the day to day things as well. If you're coming home from surgery, is there going to be someone there? Is someone going to help you with the shopping, the cooking, the laundry, the cleaning. You're going to need to go to medical appointments. Who's going to take you there while you're away? Who's going to look after your home? If you've got pets, they look after who's going to water the plants. It's all of these things because you don't expect anything to go wrong, but if there is a problem, you want to know that everything's taken care of at home while you're away and also that you're taken care of when you get back. You have to line all these things up. It might be as simple as if you know that when you come back, you're not going to be able to reach the top cupboards of the kitchen. You move stuff down in the kitchen so that you can work on the top surface or the lower cupboards. Basic problems like that that people don't ever consider.

Allan: 34:18 Well and they need to. I think that's what we're really kind of coming out here is there's like a huge opportunity, opportunity to save time to get things done sooner, opportunities to save money. But you do have to do the homework. You do have to think through these and be really logical and get really deep on understanding what your process could and may look like because it's not necessarily going to go to plan. So are you in position where you can actually manage through all that? So it was a lot more considerations than I actually had originally thought this conversation was going to have before I read your book. But I really appreciate that you took the time to really go through that in detail. And so the book is called Medical Tourism and I do encourage anyone that's considering it to check out that book. But I have one last question for you, Janet. I define wellness as being the healthiest fittest and happiest you can be. What are three strategies or tactics to get and stay well?

Janet: 35:15 I think we have to be easy on ourselves. I think all of us can improve our health in some way or another. And I think it took us a while to get to the state we're in where we think we need to improve our health. So we need to be easy on ourselves and take small steps towards changing lifestyle and eating habits. Because if you do things drastically, you're not going to do it. If you're going to cut out everything to make these huge changes, you're going to resist it. You're not going to do it. And I think that you need to be working every day towards that health goal. So if you're thinking about increasing your exercise, you know, you might be thinking about walking, so park your car a couple of blocks further than where you're going and increase the distance you walk and increase that distance every day, every week or every month. Use the stairs instead of the elevator. Take it gradually so that if you're on the 15th floor, you don't try and do 15 floors in one day, but go up a few flights at a time, you know, then take the elevator, just work up to it. And that mindfulness, I think we all need to have some quiet time. We need to take some time each day to be away from electronic gadgets if possible to do maybe 15 minutes of meditation. And that just kind of resets us and of course really important to get enough sleep.

Allan: 36:29 If someone wanted to learn more about you, more about your book, Medical Tourism: Surgery For Sale, where would you like for me to send them?

Janet: 36:37 I have a website, so it's www.areusafe.ca and that's got information about my books on there. There's also, if you go on there, you can register and download a free checklist of questions that you should be asking for a facility and there's information about the medical tourism company that I mentioned so that that's on that site as well.

Allan: 37:09 Okay. Go to 40plusfitnesspodcast.com/417 and I'll be sure to have the links there. Janet, thank you so much for being a part of 40+ Fitness. Thank you very much. Good to talk to you.

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The new keto-friendly south beach diet with Dr Arthur Agatston

Dr. Arthur Agatston inventer of the South Beach Diet, has added a new twist to the wildly successful diet making it even better. His keto-friendly version should help you drop the weight for good. We discuss his new book, The New Keto-Friendly South Beach Diet on this episode.

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Allan: 01:00 Dr. Agatston, welcome to 40+ Fitness.

Dr. Agatston: 01:03 Great to be with you Allan.

Allan: 01:04 Your new book. It's called The New Keto-Friendly South Beach Diet and I want to say, okay. I knew about the South beach diet, but it came out at a time in my life when I didn't really have to think about what I was eating or what I was doing, so I was familiar with it being, you know, kind of a more of a whole food protein style diet. Not dissimilar from some of the other stuff that was out there like Atkins and whatnot, but still very effective. A lot of people that I knew that did the South beach Diet really got good effect.

Dr. Agatston: 01:33 Yes, and I must say you weren't that interested the I was not that interested in diet. I was always thin until I realized I was, well I didn't realize it then, but I was addicted to sugar and I was pre what I call pre pre-diabetic even though my blood sugar is, everything appeared normal. But I, once I got off the bad, carbohydrates and sugar, I lost weight and it was I guess in my early fourth reason. I know, I love your show that 40 plus fitness because things change as we age, we get more fat, less lean body mass, less muscle and bone and exercise. The proper diet becomes more and more important as we age. Although our youth today are in big trouble with their diets. So it starts early, but it is tougher, is tougher as as as we age.

Allan: 02:35 Yeah. And I definitely want to get into some of the warning flags and things that we can look to before we get there. Because again, yeah, the doctors are going to say, Oh, you're a A1C is fine. Keep eating the way you're eating. That's not necessarily the answer. Because historically, I mean if we look back and you think about it and you, you talked about bears hibernating, but you know, in a, in a sense, human beings, we went through feast and famine ourselves, you know, and we would get into that. We get into that same season when when the bears fattening himself up and we're finding the berries and the nuts and we're, we're just gorging on that stuff. So our, our bodies were kind of pre-wired to put us into, for lack of a better word, what you call it. You were doing it like bingeing like you would eat a part of a blueberry pie and then you'd go back and eat the rest of it. I think that's just natural for us to do.

Dr. Agatston: 03:28 Yes, I love the, I do love the grizzly bear analogy. We're always either storing food for either an overnight fast when we're going to sleep or you know, in our history it was more often for times of famine and it's all mammals, but it's really almost all living. Ever since we became multicell cellular organisms, we had a, have a way of storing energy to use when there was no energy available from the environment. And so the fat storage mode where when we eat, whether carbohydrates, sugar turns into fat, other than what we're burning for our immediate needs and it's stored as fat and to some degree has starch or glycogen in our liver and our muscle. And usually we needed that not only when we slept and more eating, but we never had the luxury of three meals a day.

In most of our history. We were in a sense doing intermittent fasting, which gave us time for our insulin levels to go down when we ate our insulin levels go up, we store, we store storage in fat, and when it goes down, we burn it for energy. And that important survival mechanism has been totally upside down. When we have only the feast, we don't have famine. And so we're storing fat indefinitely and really creating physiologic problems that we never had in our natural existence. And it's most recently it's the abuse of sugar, high fructose corn syrup, which is, has been important because when it was introduced, it was ubiquitous really in everything and often a hidden killer in a sense. And our intake of sugar went up tremendously, really starting in the 1980s at the beginning of our obesity epidemic.

And people didn't realize they were consuming all the sugar and it was turning into fat being stored for a famine that never comes. And that's what really messed up our physiology, caused all the modern diseases. Yeah. We think of obesity. We think of diabetes, we think of heart disease, but it's cancer, it's depression, it's Alzheimer's. And every time we bring our standard American diet called the sad diet to another country, whether it's Dubai, Mumbai, Beijing, Tokyo, they get all the Western diseases, not just diabetes and obesity, but increased rates of cancer, again in Alzheimer's, autoimmune disease, all our chronic diseases. And when, what we often see now is when people came from more traditional diets like Asians, the Japanese had been studied carefully when they moved from Tokyo to Hawaii, to San Francisco. The rest of the United States, they, we've known for years, they get increased heart attacks, but they also get increased cancer, particularly breast cancer has been very well studied in Japanese women from Tokyo to the to the Midwestern United States. And so the cancer goes up as well as the obesity, the diabetes, and the heart disease.

Allan: 07:25 Yeah, so one of the things that you got into in the book is, okay, so you had, you know, we had the South beach diet and for a lot of people that was very useful because they went through a phase where they kind of allowed their body to change its insulin mode and effectively. Then after that short phase, they could go on and start reintroducing some of the food, say before until they kind of found that balance of a whole food diet that was basically much more nutritious for them. But you've adapted that so that the new South beach, new keto friendly South beach diet is just a little different. Can you kind of compare and contrast those and and why you use the term keto friendly versus just making it a keto diet?

Dr. Agatston: 08:05 Yes. I'm one of the first things that in the original South beach by the first phase, which was the low almost Keto phase only went for two weeks and what we know now, once it did get rid of cravings, the other thing that happens when you're low, you're low carb, low sugar, low processed foods is when you run out of your starch, your glycogen stores in your, in your liver and your muscle. You then have to get fat adapted, which means you really turn on the hormones, the enzymes that break down fat and make it useful. One of the best examples is the traditional marathon lovers who get hydrate loading on the night before the marathon and the idea was to fill their livers in their muscle with as much starch glycogen, that's the storage form of sugar if they could, because within two to three hours running the marathon, they would run out of the sugar glycogen stores and they had to burn fat and they weren't good at it, so that was called hitting the wall and they ran out of energy.

Now long-distance runners have learned to be fat-adapted and that takes one to many months and it continues. And I've had that experience myself. So instead of just the first phase being two weeks, we'd go for one to many months of low processed carb, low sugar so that we can learn to use our fat for energy. And the first fat that goes is the belly fat. And today it's interesting the long endurance runners, the people doing triathlons and even more than marathons are going low carb and they don't hit the wall, they burn their fat very well. Now for the rest of us, you know, it takes 12 hours to a day. It's individual where you, you deplete your Icogenics stores and you begin to burn more, more fat and become fat adapted and allowing for that is very important.

When I first became really strict and good, it's when I realized I, I was truly addicted to sugar and I went cold Turkey once. Once, by the way, I understood that I was truly addicted to sugar, that when I cheated, it wasn't a lack of self-discipline. And what would happen to me is I could lose my cravings on the first phase of the South Beach Diet. But when I went to the second phase, I would invariably have a fruit or maybe even a whole grain bread, but I would, or a dessert and I wouldn't sop and now we know it's not a lack of self-discipline. It's truly and addiction and many Americans, especially overweight Americans are addicted. But once I got off that addiction and stayed on sort of the traditional phase one the South beach diet, I did my first, I was, I started the diet while on vacation and I came back and I returned to my, to my boxing, which I did regularly. And I still, I recall vividly, it was a Tuesday morning in late September, hot in south Florida. And normally I would take a round or two off when I did my boxing and all of a sudden I didn't have to take around off. I went continuously for eight rounds and now I can 12 rounds, three minute rounds with a minute and a half rest.

Allan: 12:12 I do have to say this, if you haven't done boxing as a workout, three minutes is an eternity. I have some clients I do some boxing with and you know, we'll go for a minute. I've gotten one, I'm up to about a minute and a half and they're, they're done. You know, like I need a break. And so going, just even going a three minute round is saying something. But for you to have the endurance to be able to, you know, go round after round with what about a minute rest between rounds. That's, that's pretty impressive.

Dr. Agatston: 12:40 For my tender young age, I take an answer 30 seconds in between rounds.

Allan: 12:45 No, but still three, three minutes is a lot of time to keep moving.

Dr. Agatston: 12:49 Yes. And I couldn't in hot, difficult conditions, I would always take rounds off and since I'm fat adapted, I don't, I feel better physically and mentally and that much more than the cosmetics of losing my belly. And then remember I was a diet doctor. My wife used to say, Author, no more TV for you only radio. You get rid of that little belly and so, but it's much more the way I feel and since we've been, we've been more flexible with our patients. The results we see are incredible and besides the fat adption, the longer sort of phase one, the other idea is you don't have to be in full ketosis. Actually, when we're in the fat burning mode, we're often in ketosis. It's the levels we can't measure easily by current methods, but you can, you can lose the belly.

You get all the benefits without actually being in ketosis. The big advantage of ketosis, particularly for people who are diabetic, who really want to jump into something strict, is you can measure your ketosis and you can document compliance and that's, that's good for us often and our patients. But to make the diet a lifestyle, there still has to be more flexibility. We also encourage either time-restricted feeding or intermittent fasting. And we do suggest that with full keto, with fasting that you do it with a nutritionist, to health coach or your physician, your physician so that you can avoid problems such as what's called the keto flu. But so we are flexible in our approach depending on our patient, the needs, the desires and you can even be a vegetarian low carb as long as you're having whole foods and not having other process carbs. It's tougher but you can do it. And of course traditional societies that like the Asians with rice and not the Okinawans with with sweet potatoes, they were some of the, well particularly the Okinawans were some of the longest lived populations in the world, but they didn't eat snacks all day frequently. And now to the degree that sugar has shown its ugly face in all these societies, they are becoming overweight, diabetic and all the Western diseases that had been in the United States for decades.

Allan: 15:48 When you put this together, I mean cause like one of the things you said and I think that's really important is, well a couple of different things, but one that I thinks is really important is that we all are gonna have different needs. We're all going to be slightly different from a biology perspective of how we want to apply this. So there's, there is a lot of flexibility to this to say, I know, okay if I need to lose 30 pounds or I am diabetic, I'm probably gonna stay in phase one and be a little bit more strict and probably get to a point where I am in ketosis if not completely, at least most of the time I'm eating at that low of a low carb. But you have 12 rules for what you call keto friendly eating. Could you just kind of go through those rules with us? Cause I think that'll make a lot more sense to folks when they see, okay. It is really kind of flexible. It 12 rules sounds like a lot, but they're just the basics of if you're eating this way, you're going to be much more healthy.

Yes. And by the way, yeah, you got it exactly because the flexibility is we all come with different degrees of we call the thrifty gene and the tendency towards becoming diabetic ultimately. And so the rules are first minimize sugars is number one. And we might say no sugars, but you know, our parents and grandparents who had the sugar cube in their coffee was a lot different with the amount of sugar we're getting today. And so you can burn some sugar without having stored it. It's the volume that is totally off the charts today. And refined carbohydrates are absorbed more rapidly than whole grain or high fiber carbohydrates. And by being absorbed more rapidly, they, it's called the incorrect in effect, but they increase our insulin levels out of proportion to just the increase in blood sugar, blood sugar alone.

So if you give blood sugar a certain amount intravenously through the vein, the blood sugar goes up a little bit and the insulin goes up a little bit. But when you consume it, then you stimulate hormones. It's something called GIP, which causes an exaggerated increase in insulin. And that's, that's the problem with frequent feeding. And snacking, which we used to say, like everybody said, when you went to the South Beach Diet, have frequent snacks to stabilize your blood sugar, your insulin levels. That was just plain wrong. So the third rule is, is limit snacking. You want to give time for your insulin levels to drop and that's where having very low glycemic foods, whole foods or nothing for breakfast and lunch, that allows your insulin levels to go down. And that's when you can start burning fat. When your insulin levels are high, you block the burning of your fat stores.

So you can be once the, insulin levels stay high and you can't access your fat stores, you can be starving and you run to the fast-food restaurant or you have a coke that doesn't even suppress, doesn't even, doesn't even fill you up. So you want to give time for your insulin levels to drop by not snacking, having fewer larger meals, which is the next in the 12 rules or having foods that are absorbed further down in the intestine and don't increase your blood sugar and your insulin levels. We say maximize the healthy fats and one of the things is while some people I know don't like dairy cause they're sensitive to it, well saturated fat in meat, in dairy, we now know raises your large LDL bad cholesterol particles and they do not cause heart disease.

This is relatively recent knowledge but it's done. It's been repeated in several large studies. It's the small LDL particles that cause heart disease and they come from sugar and bad carbohydrates. And one other point that out the bad carbohydrates is again, it's volume. Because when you have a bad carbohydrate, you either burn it or if it's glucose, not sugar, you can store it as glycogen, as starch, but only so much about 700 calories. Then you then it turns into fat.

Allan: 20:50 Yeah. But that's part of the problem is these processed carbohydrates are process to basically make us eat more. That's what the food manufacturers are doing. If you don't eat, let's just say you're not going to eat one Pringle. You could eat one Pringle and maybe you'd love the taste of it and that would be all you needed. Your body could absorb that and you'd be fine, but invariably it's a long sleeve and you're not just going to eat one.

Yes, absolutely. And one of my favorite books by Dr. Robert Lustig from UC San Francisco, the Hacking of the American Mind, and he talks about how the food companies make us addicted. And yeah, I mean sugar. I seen another friend, Dr. David Ludwig, did a study where they gave Cokes to teenagers before they ran into a fast-food restaurant and they ate more, not less because fructose, the sugar in the cokes does not suppressed. There's not suppress your appetite. It actually increases. And again, those processed carbohydrates including sugar are absorbed at the beginning of your small intestine or you get that bad incretin effect where your insulin goes way up, and sugar is not turned into starch or glycogen in your liver. It's either burned or it's turned into fat right away. So a high sugar diet is a high-fat diet. And then we say, you know, limit the Omega six vegetable oils.

Of course, the original vegetable oils, and they're not made from vegetables. They're made from, from seeds. The first were made from cotton seeds now soybean and many other types. And they originally they were hydrogenated for shell finding and that was shown not to be healthy, to be very unhealthy. They were outlawed. But instead of going to just traditional saturated fats such as lard, butter, coconut oils or olive oils there going into nonhydrogenated vegetable oils. And Americans were never, humans, in general, were never exposed to naturally. We need small amounts of these or else they're called on your Omega six oils, which today are the vegetable oils and small amounts are fine, but when you process them and create the salad dressings, the cooking oils, we were never meant to have that many oils and it throws out our Omega six inflammatory measures to Omega three oils which are anti-inflammatory.

So where our ratio of omega six to omega three should be from one to four to five to one in most Americans its greater than 10 to one. And so you should be avoiding all vegetable oils as far as I'm concerned, it's proinflammatory but your vegetables and you know the nonstarchy vegetables, asparagus and brocolli, Brussels sprouts and green leafy vegetables, the spinach, those are all good. Yet when the problem is when we always talk about fruits and vegetables because a lot of fruits have a lot of fructose, particularly the tropical fruits, so fruits have anti oxidants that could be good for us when it's a whole fruit in the form of a Berry, but a lot of people think they're being healthy cause they're having a lot of fruits and they can overdo it because of the sugar and the fructose that makes the fruit sweet so we shouldn't be always loving vegetables and fruits and fruits together and then a wide variety of needs, poultry, seafood all very nutrient-rich and eat primarily whole foods.

The best example of this I think is the field cut truly whole grain oats versus instant oatmeal and with actually the same amount of fiber when you have the steel-cut oatmeal, the sugar or the or the starch core of the oat is surrounded by fiber. It takes a while to digest and releases the starch, the sugar into the blood stream slowly and you stimulate the enzymes further down the intestine that are good when you have processed instant oat meal. Even if you have the same amount of fiber, it's not surrounding the starch core and so it's absorbed much more rapidly. The enzymes, the hormones have direct access to the starch, it turns to sugar instantaneously and that increases your insulin levels rapidly and you're much hungrier. The studies have been done, you're much hungrier sooner than if you have the steel cut true oatmeal.

So, and that's true of eating whole foods and that means whole foods adding the fiber in separately. There's just a lot less evidence that that's helpful. And flexibility. It's more important not to be snacking and not to be eating frequently often than sometimes what you eat if you're eating in a relatively small window or during intermittent fasting. I hate to say, you can get away with more because you do increase your starch stores and your insulin, but then you have a long period of time to burn off that starch and the fat that's been consumed. So we prefer whole good foods all the time. But if you're going to be, if you're going to cheat, cheating in a short window is much better than if you're grazing and eating all day. That's disaster. There were snacking very well documented where we're eating many more times per day than we were in the 1970s and it's cause we're walking around hungry all day because our blood sugars are swinging around and our insulin levels are high and we don't have access to that big store of fat in our bellies.

Allan: 27:38 Well, and I think flexibility is important, but this is not, we're not talking about a license to just say, okay, I'm going to allow myself to have a piece of cake every night because I can, I'm only having, you know, two big meals a day and therefore I know I can have, and that's great. But if you're wanting weight loss, if you're diabetic or prediabetic or as we're going to get into in a minute pre pre-diabetic, then you have to understand, or you no you're addicted to sugar. You really have to think hard about how you can approach this and use this diet as a tool to get yourself healthy, to get yourself off that addiction because it's possible. But if you're going to start the game cheating, you probably not going to get there very fast.

And by the way, I mean that is the mistake that I frequently made without knowing. But even now, I mean, in the holiday season, if I'm acting in a fair, and this has happened and I, you know, and I eat the wrong food, the addiction comes back so quickly. And other than that, knowledge of I I can't do this or I can't keep doing this and I can get back on the wagon pretty quickly. But you're, you're, you're absolutely right. This is not a license to be cheating every night. I mean, the good thing if it's once a month or you know, somebody loves their pasta meal and there's a good amount of protein with it. And that's, that's again, depending on the individual, some people will immediately fall off the wagon and get into big trouble. Others, I always have patients who don't have the sweet tooth I have and they can have a bite or something and have a bite, you know. In Miami we have, we have Joe's stone crab and their key line pie. And I generally can that have just one bite. So I don't have it at all. And others can, including my wife. So that's knowing how each of us are as individuals.

Allan: 29:44 And that's one of the things I liked about your book was it took that into account and said, you know, because now you've dealt with thousands of patients and yourself and it's like we're all going to have to approach this slightly differently and we're going to figure out what works for us and we're just going to have to be self aware that you know, if we have this addiction, if we have this issue. One of the things you had in the book, which I thought was really, really important because by the time you go to the doctor and your A1C is over six and they're going to start now diagnosing you with diabetes, you're way down the road and you talk about some tests, some things we can look at before we even get to that point. And so these are tests I'm actually kind of interested in having done because my A1C is great. My blood sugar is great, but that doesn't mean I'm out of the woods. It just might mean that right now my body's creating a ton of insulin and it's able to shuttle all of that blood sugar away so I don't stay in a high blood sugar state. So one of them you call was, it was basically the insulin resistance test or you know, insulin. And then the other one was called the Atkinson calcium score.

Yes. The first, as far the points you've made about insulin are so, so important. So in fact, if we take in America healthy young, 20-year-olds, not overweight today versus the 1970s their hemoglobin A1C, maybe five are they're very normal. They're fasting. Blood sugars are absolutely, absolutely normal. They give a glucose tolerance test where you take a drink of 75 grams of sugar, glucose and wait two hours, their blood sugar comes down. But if you measure the insulin levels, it's taking four times normal insulin levels to keep their blood sugar normal. And that's already hacking fat into their liver, if you anybody, even teenagers, if you see a belly on anybody, a little protrusion, it means they have high insulin levels and they have excess fat in their liver. That's where it all, it all starts. So the test that we do, we call it the insulin secretion test, your insulin-resistant test.

It was actually developed by Dr. Joseph Kraft in the 1970s he died recently at age 94 and unfortunately, he did great work. Unfortunately, it was not recognized by the nutrition establishment, including the American diet. I thinks its an association. Partly, you can only measure insulin levels. In the 1960s the developers undercut the Nobel prize and hasn't been measured clinically until very recently. But he did the measurements when it was very expensive, but on 15,000 patients and he found that he called it diabetes insight too. I call it, it's kind of a medical term, I call it pre prediabetes because anybody with high insulin levels is having problems already, whether they know it or not. Including depression. There is an epidemic of colon cancer in young people, breast cancer, which are related to high levels of insulin. And so the real tests you need, which I'd like to give Kraft credit, called the Kraft test, is you take the insulin, the glucose drink, which was given in the traditional oral glucose tolerance test.

All pregnant women today get the oral glucose tolerance test, and instead of just measuring blood sugar, you measure insulin levels. And so, so many people who have bellies and some, are what do you call it? TOFI. There's thin on the outside and fat on the inside. If you look with a CT scan, cat scan of their belly, they have belly fat. Even though from the outside you would never realize it. And so you can really only tell, you could do it if you do a special MRI of the liver, but that's too expensive and not practical. The Kraft insulin secretion test, it's not expensive. The main thing is it's done over two hours. You do a fasting in some level, then you drink the glucose and then you repeat it at 30 minutes, 60 minutes, 90 minutes and two hours. And so we see patients who already have plaque in their coronary arteries, they have all kinds of chronic illness and their A1C is normal.

And so the fact is it takes years to develop. The fat is not only in your liver, it's also in your pancreas, and it's not till your pancreatic beta cells that make insulin, that synthesize insulin, become injured by the fat in the pancreas and you can't make enough insulin to keep your blood sugar normal. That's when your A1C, your fasting blood sugar goes up. And that's when we diagnose you have a problem pre diabetes or diabetes. But in fact, 10- 20 years before you can measure high insulin levels and people are suffering from again, skin problems to having cancer to heart disease when they're told your blood sugar is normal, don't worry about it. So that's, it's so important to understand. If you have a belly, you have high insulin levels, you're at risk of having heart disease, diabetes and cancer and Alzheimer's. Even though your doctor say your blood sugar is normal. So it's very important to get that word out right.

Allan: 35:43 And then the calcium score is basically going to tell us how much plaque is built up already.

Dr. Agatston: 35:50 So yeah, the calcium score I developed with my colleague Warren Janowitz. And if you're heading for a heart attack, if say you're 40 years old and you're heading for a heart attack when you're 50, 55, 60, you already have plaque in your coronary artery. And with the calcium score, it's inexpensive. In Miami, it's $99. At Johns Hopkins, it's $75 to have the test. You can,uand it's essentially no radiation. It's a cat scan that has some radiation, but you get more radiation when you, when you fly in distance. So the radiation is not an issue for cost is really not an issue. And even though your cholesterol might be normal, things can look normal.

But again, if you have a lot of small LDL particles and other problems that are hidden, you may be developing plaque and you can't tell with a cholesterol test, LDL test or any other tests. Here you're looking directly in the coronaries with a safe, inexpensive test and that tells you what your risk is of a future heart attack. But it also, it predicts all cause mortality because it indicates how the various risk factors for chronic disease are mixing in you as an individual. So the one thing that we see now is we see people whose hemoglobin A1C, their blood sugars are normal, but they have high insulin levels. They may have some other genetic markers that we look for cause you're my practices is cardiac prevention. But those tests are not so difficult to get either. But the main thing is that with the high insulin levels, the sugar and bad carbs they're consuming is turning into fat in the liver and they're overloading the liver with fat.

That causes a lot of problems. But one thing it does is it turns the normal LDL in to small dense LDL, small LDL particles that are not cleared by the, in the bloodstream easily. They don't fit into the usual receptors. They become oxidized and the oxidized LDL sticks to the vessel wall. It gets underneath the vessel wall, builds up the plaque and we again can see with the calcium score, you can see the build up of that plaque and the result of the high insulin levels years before you get chest pain or a heart attack and you can monitor it and then can prevent it.

Allan: 38:36 And I think that's huge. You know, so many of the tests and the things that we get diagnosed with, we're already sick and this is an opportunity for you to catch it much, much earlier, even if the other tests are coming out relatively clean these are really cool. I, I really appreciate this cause I was having, I mean I remember interviewing Dr. Fung and his, his book about the Obesity Code, and back then and he's like, you know, it didn't make any sense to measure insulin because you're doing it fast and you're doing it one time. But you know, here's some advancement where we're saying, well let's, let's go ahead and test the other side of this. The sugar is glucose equation. Basically using the same test, just looking at the actual insulin response, which I again, I think that's just brilliant.

Dr. Agatston: 39:17 And I yeah, I admire Dr. Fung a lot. And but you can't just measure the fasting insulin. We have people with normal fasting insulins and I'm particularly young people are at at 30 minutes after the glucose load their, I mean their insulin levels are in the hundreds, whereas their fasting glucose is normal. In older patients, you get more and more of the delay in the insulin, which indicates dysfunction of the beta cells in the pancreas that are making insulin. And that's because fat, we know that you get a fatty liver years again before you're diabetic or, or even pre-diabetic. And the fat is also going into your pancreas and interfering with the beta cells. And so you get a delay in the insulin secretion. So we can see both the degree of insulin resistance and the degree of what we call beta cell dysfunction, the pancreatic dysfunction that eventually is going to lead to the high blood sugars when you can no longer make enough insulin to keep the blood sugar normal.

And the other thing with this delay in the production of insulin is the insulin peeks hours after a meal and it stays high and that's that high insulin level that is locking in the fat after a meal. So when people get up in the middle of the night starving, even though they have all these fat stores in their belly, in their liver, in their muscle, the problem is they have sustained high insulin levels that blocks the enzymes that breaks down the fat and gives you the energy in the hibernating bear late in the fall. The bear is, they're eating the fruit that's become ripe. That's why fruit is seasonal and they are ravenous, depleting the forest of blueberries and other berries, even though the bear has already put on 400, 600 pounds of fat, but they don't have access to the fat because their insulin levels high. So they can continue to put on the fat for the winter hibernation.

Once they're hibernating and they're not consuming that fruit and the fructose in the fruit, then their insulin levels drop. Now they have access to the fat and that's how they hibernate the whole winter without eating because its that fat that is helping their brain, their kidneys, their heart to continue to function while they're asleep. So normally when we sleep every night we're not eating, so we're accessing our storage starch and fat. But what our insulin levels are high, we can't. So the blood sugar falls and we may wake up in the middle of the night starving and go to the refrigerator and have whatever sugar and carbs are there to bring our blood sugar back up. So it becomes a really vicious cycle.

Allan: 42:36 Yes it does. And so I think this is, you know, we're, we're into January here and I think, so this is kind of a great time to look at something like the Keto Friendly South Beach Diet because it's going to help you regulate your insulin. It's going to help you kind of go through a good period now where you can be thinking in terms of the bear or humans and what we would and wouldn't be eating. The rules are pretty simple. You do have meal plans in there and recipes so it's all put together very well. So again, I think this is an excellent opportunity to take something that worked. The South beach diet definitely was one of those things that people, when they follow it, it worked and you've improved it, which I think again is just wonderful.

Dr. Agatston: 43:16 Well thank you. Thank you so much. And Allan, I mean you obviously you really got it. And it's part of the book is certainly understanding the principles because even for me, who was the cardiologist diet doctor telling, putting my patients on diets for years, but I didn't understand the addiction aspect. Once I did it made such a difference for me and it is, it is for my patients. So this was not necessary eating differently. I mean it was the understanding that made me stick to principles that I already knew. So understanding the role of insulin and how it's different for all of us and understanding flexibility, understanding that America is not overweight because we all of a sudden lost our discipline or for that matter have stopped exercising. Exercise is very, very important. But what causes, what's caused the obesity and chronic disease epidemic is mainly, it's mainly the way we're eating.

Allan: 44:22 I define wellness as being the healthiest, fittest, and happiest you can be. What are three strategies or tactics to get and sta well?

Dr. Agatston: 44:32 I would say understand insulin, keep it down, don't snack between meals, try some intermittent fasting and others is getting a good night's sleep and this enters in. Of course, if you're overweight and have sleep apnea, you may not be able to sleep proper, but we know a lack of sleep. Again, it stimulates enzymes and hormones that lead to high insulin levels and the other is regular exercise. And exercise is not going to be a solution from the calorie burning aspects. They prove that on the Biggest Loser for your, for your brain, for insulin sensitivity, for keeping up lean body mass. And you know I, you know, I love your podcast and the and being well over 40 plus that we have to keep our muscle and our bone. And you know, when we weigh ourselves, it's the weight, the BMI doesn't really mean anything because that includes, muscle, bone and fat under our skin, when we call the subcutaneous fat, it's only the fat in and around or origins.

That's the dangerous fat that we have that we have to worry about. And regular exercise, it improves our brain function, improves our sensitivity to insulin. So it decreases insulin resistance and it helps us age. We sustain lean body mass and on balance and so many things that's part of healthy aging. And I agree with you. Wellness, we use the term optimal health and it's, it's your vitality. And again, what's kept me on the changes in the diet that I made is I vitality, my ability to exercise, my ability to concentrate, get rid of the brain fog. And it's all those things. My belly was often hidden, people couldn't see it where I was wearing clothes but I knew it was there, but it's because I feel so much better with this and this type of lifestyle. So sleeping right, my exercising right and eating right.

And as you age you have to be more and more concerned about each of these elements. And so I really applaud for what you do with 40 plus as we age, we do become more insulin resistant and it becomes tougher and tougher and you have to get enough sleep, enough exercise and eat the right foods and not eat too often.

Allan: 47:18 Great. Thank you for that. So Dr. Agatston, if someone wanted to learn more about you or learn more about the book, The New Keto-Friendly South Beach Diet, where would you like for me to send them?

Dr. Agatston: 47:30 South beach diet website changed recently.

Allan: 47:36 Okay. That's good. Yeah. Just send me the link and I'll make the show notes so you can go to…

Dr. Agatston: 47:41 Agatstoncenter.Com is our office, our website. It has all of information too.

Allan: 47:48 Cool. Well you can go to 40plusfitnesspodcast.com/416 and I'll be sure to have those links there. So Doctor, thank you so much for being a part of 40+ Fitness.

Dr. Agatston: 47:58 Thank you Allan so much. It was really enjoyable.


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Another episode you may enjoy

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January 6, 2020

Carnivore cooking with Craig Emmerich

As more people adopt different ways of eating, the carnivore diet is gaining rabid followers. Today we bring back Craig Emmerich to talk about the carnivore way of eating and the cookbook he and his wife, Maria wrote called The Carnivore Cookbook

Allan: 01:29 Craig, welcome to 40+ Fitness.

Craig: 01:32 Thank you for having me on.

Allan: 01:34 You know your cookbooks now. You're working directly with Maria to do the cookbooks and those cookbooks have been some of my favorites across, including Keto Comfort Foods, which made my list of favorite books that I've read because of the recipes that she has in there. Her etouffee is just unbelievable There's also Keto Restaurant Foods. You recently sent me one on air fryers, which I'm just now diving into. We don't have an oven in our apartment here we didn't realize that until we moved in. It's like we have a stove top and no oven. I'm like, huh. Air fryer. That might do it. A very small place. I'm going to be diving into that big, big time.

Allan: 02:13 And then your book now The Carnivore Cookbook. When I first started hearing people moving to carnivore, because the conversation went paleo, keto started kind of gaining momentum, and now carnivore. It was almost reminiscent of the vegan approach to eating. It's such a huge elimination diet that I was like, I don't know that I would ever try that, but I'm glad you sent me this cookbook. I'm glad we have this opportunity to have this conversation because I learned so much from this book.

Craig: 02:51 Thanks, Yeah, we tried to put a lot of, you know, it's much more than just a cookbook. You know, it's got over a hundred pages of content of why. You know, just the general question of why carnivore and I think the book covers that pretty well.

Allan: 03:07 Yeah. I would get on these Facebook groups and everyone's like, Oh no, you don't, you don't need that. You can just eat rib eyes all day every day. Or bacon. That's the same thing with Kito. I'm like, get off the bacon please. We need a little more than that. And I was really appreciative. I figured there was no way that you and Maria would put out a book without at least giving us some basis in science and some, some general howtos before we ever even try something like this.

Craig: 03:32 Yeah. That's what Maria and I, we've been doing this for over, Maria for over 20 years and we've always based everything we do on science and the, things we read and we're constantly learning and we're always looking for the latest information to, you know understand and, and understand this lifestyle and what the science is saying about it and our biology and all of that. And we incorporate that into, you know, our books and what we do with clients. And so, you know, things have evolved over the years. We used to recommend flax and we no longer recommend it. Probably eight or 10 years ago, we read more on the estrogenic compounds and what they you know do to people. And if they're with estrogen balance and so we'd no longer recommend it. So, we always try to keep up and learn and educate ourselves.

Allan: 04:25 And I appreciate that. That is part of what this podcast is all about. I'm generally agnostic until someone gets militant about their way of eating which is happening on all sides of this. I think a lot of us went through the evolution of the paleo, keto. And now people are looking at carnivore and other kind of spinoffs of keto. I've even seen some vegan keto that's out there and we've covered that on the podcast. And so I encourage people to explore these.

Allan: 04:56 Now with the carnivore diet, it's, the way I'm reading it, we have gone through this is it's basically an elimination diet. And a lot of people will get into it predominantly for weight loss. Maybe they stalled on keto and they're not losing any more weight. And they're like, well, what do I do? And seems like, well, you know, I went on the carnivore diet, I lost an additional five pounds in a week. And they're like, Oh, okay. And so people are experimenting with it. So it's important for them to understand what this diet means. But at the same time, it's there's, there's a reason we're going to do it besides weight loss for a lot of people. Including yourself.

Craig: 05:37 Yeah. So, you know we took the book when we started talking about applying this diet we took it in two parts and we said, okay, what are your goals? Why are you doing this? And if the goal is weight loss, then great, here's kind of how you do it and how to get success doing it for weight loss. And then we took the other angle of, are you doing it for healing? Because that can be a little bit different when it comes to, you know, healing from auto-immune disorders or bipolar or Lyme disease. Like I have those things require a little different protocol to kind of weed out what you can handle and what your body reactsto or not. And so that was, we coined, we called it the carnival auto immune protocol and it's basically, you know, just like an autoimmune protocol or it's an elimination diet, but it's a total elimination diet.

Craig: 06:36 And you start out just eating beef and salt and a take it back to the basics and allow your body to adjust to that and then slowly add things back in. And this is a way to find where your tolerance level is. And it's so important because people like me with Lyme disease that I've struggled with now for seven, eight years with, you know, chronic pain, especially the, the hardest thing is the migrating pain that I get where, you know, you wake up in the morning and it feels like you sprained your knee, you didn't do anything, you just wake up with this knee pain. Next morning you wake up, it's in the other knee or in your hip or your ankle. And it's very hard to function when you've got this because I mean it's just hard to even walk around with carnivore I was able to completely eliminate that migrating pain.

Craig: 07:27 And by eliminating certain plants and things that I eat used to eat when I was keto. And so it's a powerful thing. And there's even people in this community like Amber, our friend Amber O'Hearn, she's been carnivore for like, I don't know, 15 years and it's to help with her bipolar. With keto she saw improvements but not total stopping of the progression of the disease. With carnivore she did see a complete stopping of the progression. So, you know, this is not, I look at this as how we've always approached keto in that people come to keto and yeah, the weight loss is great, but they stay with it because of the healing effects and how much better they feel and a lot of the carnivore is in the same realm is that, you know, people especially with these, you know, chronic autoimmune or Lyme or these chronic pain conditions, they come to it and they see relief and that is the driving force behind it.

Allan: 08:34 And I think that's one of the cores here is that this is for some people this could just be a temporary, you know, I want to lose 20 pounds. I'll try carnivore and I do it for 28 to, you know, I don't know, six weeks, six months, whatever. You lose that weight and then you can start incorporating, you know, plant material back into your diet, and became basically keto from that point forward and feel pretty good about.

Craig: 08:59 Yeah, keto or low carb. And you can, you know, live that way for a long time and forever. And you know, Maria's been keto for, like you said, over 20 years and she's thriving and you know, she kind of goes back and forth herself. You know, she'll, there's days where she pretty much eats carnivore and then other days, you know, maybe like this weekend and we're going to family outings, you know, she'll incorporate salads and, you know, other things basically eating keto you know, myself, I'm still gonna stick to the meat because if I don't, I'm gonna be in rough shape that next day with the pain. So, you know, it really depends on your goals.

Allan: 09:39 Now you've mentioned in the healing part, you mentioned the Lyme disease, which is what you're familiar with particularly. And then of course the bipolar. Some of the other conditions you had in there included gout, which one of my clients suffers from. It's kind of hard. I can give him workouts and say, Hey, you know, go to this workout. But then, you know, he has a gout flare up and he's bedridden for a week. So that's not helping him. Is the state's going to help other things you had got listed, I believe. There's other items out there and exactly what do we think is happening in our bodies that's allowing this to be so effective? If you ask someone a doctor about gout, they'll say stay away from red meat.

Craig: 10:21 Yeah, I mean, that's a common myth, but you know, most of gout, lot of times it's related to fructose and as well as possibly oxalates. You know, there's some evidence that oxalates are one of the anti-nutrients that come with plants, plants, all plants have anti-nutrients. And this is something I would really want it to talk about in the book because I think this is one of the components that helps people like me is that you get rid of all these things your body doesn't really want. And when you're at a state like mine where lyme disease really chronically depresses your immune function and puts you in an inflammatory state. And so removing additional inflammatory components like anti-nutrients can help the body. And so all these anti-nutrients are basically compounds the body can't use and doesn't want. So it has to detox.

Craig: 11:16 There's tons of antioxidants, there's thousands of them in anti-nutrients in thousands of them in plants. Some of the most harmful are things like oxalates and phytates and glucosinolates and these compounds that are basically natural pesticides for the plants to kill off bugs or things that try to eat them. You know, a plant is, you think about it from an evolutionary perspective. Animals can defend themselves by growling, showing their teeth running away. A plant can't do any of those things. So it's the natural defenses that are basically natural pesticides. So a plant does not want you to eat the STAM, the roots or the leaves because that kills the plant. So it only wants you to eat the fruit. So the fruit, it makes sweet and tempting to animals. And then it has natural pesticides on its other parts that keep bugs and things from eating them.

Craig: 12:18 And there's actually toxicity levels for some of these anti-nutrients things like oxalates it's anywhere from three grams to maybe 30 grams of oxalates can kill you. It's a wide range because of immune function and metabolic state. So somebody has diabetes or Lyme disease or chronic issues or depressed immune function. They might be closer to three grams of oxalates that could actually kill you if you're very healthy. It might be more like 30, but a man did die eating too many oxalates in Europe and it's been documented. So, you know, this is something that we don't understand about plants. We've been taught our whole lives, that fruit and vegetables are unlimited. Eat as much as you want, but there are some negatives and especially if you've got a disease state, they can really hinder you.

Allan: 13:11 Yeah. You know, and they'll tell you, you know, when you go to lift weights you're, you're, you're doing some damage to the muscle. And then this process called hormesis is what's allowing the muscle to build back stronger and better. They used to tell us now, they would tell us with vegetables is that, you know, yes, they have these anti-nutrients, but your body under normal functioning can goes through hormesis there as well. So some of the advice I've heard before is a breakup your kale 10 minutes before you're ready to start cooking it so that it maximizes these anti-nutrients. And so, yeah, it, you know, I, I guess I, if you're, if you have a normally functioning immune system and everything's working out for you, you probably have that opportunity to improve from that stress. But if you're dealing with an auto-immune issue of any type, now you know, you're, you're in that situation of too much damage.

Craig: 14:06 Yeah. Additional stress is not good in those situations. And so yeah, I think the mechanisms for all these different conditions where you can see improvements with carnivore are a couple fold. Number one is that that aspect, the anti-nutrients you don't have to deal with anymore and additional stress on the body. The other aspect I think is nutrient density and bioavailability of those nutrients. If you think about healing the body, what do you need? You need lots of vitamins and minerals to help the body you know, very nutrient dense foods to help the body recover and repair itself. Well, what is the most nutrient dense food when you, especially when you consider, well, that's going to be animal proteins. We put a lot of charts in the book to kind of explain this, but the very important aspect of it as well is the bio-availability of those nutrients because there's a lot of these anti-nutrients that can leach these nutrients from the body. So what I mean by that is we give the, there's a study that was done that took oysters, which are great for zinc. They're very high in zinc and they might've..

Allan: 15:20 And my favorite food by the way.

Craig: 15:21 Yeah, me as well. When I can get them, we can't, don't get them a lot in the Midwest.

Allan: 15:26 We don't, we don't get them down here in Panama. So when I travel back up to Louisiana, Florida, I'm hitting the oyster bars for sure.

Craig: 15:33 Yes I did. Or you know, high in DHA. So they're really good food for you. But what they did is they tested postprandial glucose, blood zinc levels. So basically the amount of zinc that's getting into the blood from eating the oysters. And when they did it with just oysters, you get this nice increase in zinc in the blood. So you're getting all this zinc into the body. When you eat, when they had the participants eat the oysters with black beans, like a third of the zinc gets into the body. And then when they had them eat them with corn tortilla chips, none of the zinc gets into the body. And this is, I believe is because those anti-nutrients like oxalates that latch on to minerals. And then when they're detox, they go right through the body. So the body is basically robbed of these nutrients. And so going the carnivore eliminates any of that from happening. And you get this huge dose of vitamins into the body that your body hadn't been getting. And, and that helps with healing.

Allan: 16:38 So let, let's get into that a little bit because you know, some of them say you can just sit down and it's just eat meat. You're, obviously, well, maybe not so obviously not getting all the vitamins and minerals that you could get from vegetables and fruits, but what you're saying is all of the necessary vitamins and minerals are available in animal products and they may be even more bio available to us as in, in addition to that.

Craig: 17:10 Yeah. And you know, the charts that I put in the book, I tried to kind of show that we have I think about 15 vitamins and minerals, a list of in these charts and they compare the content of, you know, beef, beef, liver, kale, you know, broccoli, all of these foods. And what you see is that beef by itself stacks up really well against those other foods. I think in the one chart I did have just beef, like a steak versus kale, blueberries and an Apple. Beef is number one in the vitamins and minerals in 13 out of the 15 vitamins and minerals and number two in one other one. So it's either one or two and all but one. And I think the only one it wasn't was vitamin C, which vitamin C is your requirement for vitamin C in the body is, is directly proportional to the amount of carbohydrates you eat. The less carbs you eat, the less vitamin C you need. So it's my position that especially if you eat a nose to tail type of carnivore diet where you incorporate things like beef liver and you know, bone marrow and these kinds of things. You're getting all the nutrients your body needs and it's in a more bioavailable form than you get from the plants.

Allan: 18:33 And, and like I said, I, I trust you and Maria so much that I knew when I started flipping through the recipes, you were going to be giving us some advice on how to get liver and bone marrow into our diet on a regular basis. Even for those who have difficulty with it. Can you tell us your trick, your trick for getting liver into, into your meals? Even when you don't necessarily like the texture, flavor of liver?

Craig: 18:57 Yeah, there's a few things that we do. Even if you're not carnival or if you're looking at a keto diet, a lifestyle, even in keto, it's great to incorporate some liver cause there's probably nothing on the planet that's more nutrient dense than beef liver. I mean that is like nature's multivitamin. So we try to incorporate it wherever we can. One of the great things that you can do is mix it into hamburger at like a five to one ratio. So for every five pounds of hamburger you put a pound of ground liver into it and you mix it all up and it makes amazing burgers. Or you can make, take that and make it into things like Maria's protein noodle lasagna or her chili recipe if you really averse to the taste. Chili is a great one because the more spice there is, the more you kind of cover that taste and you and usually in our chili recipe, you don't even notice that it's, if you don't tell somebody, they won't know that. It's not that there's beef liver in there.

Allan: 19:53 I wouldn't advise that because when you tell them afterwards, they're going to be pretty angry with you.

Craig: 20:00 Maybe with your kids,

Allan: 20:02 Just get them to try and say, Hey, try this, try this meatloaf. It just, just to taste. You might not like it, but just try it. And if you like, it's from Maria's cookbook, I know it's going to be good, but here try this. And if you don't like it, then I understand. But yeah, don't, don't sit down to dinner and then tell your whole family what you did later.

Craig: 20:21 Well, actually we like to let our kids pallets do the talking. You know, one of the things that Maria gets annoyed by is like, her mother will sometimes say to the, Oh, Omray you might not like this. This is Maria's healthy pancakes. Well now the kids are going to hate it. Yeah. Just let them try it. And if they like it, great. You know, they don't need to know that. That's the healthy one.

Allan: 20:45 Yeah. I get it with kids, I get it. With your spouse, you might want to say I'm going to try this experiment. I want you to try it with me. Are you game? If not, I'll eat all of it. I promise I'll eat every bit of it. I just want to share this, this healthy meal with you.

Craig: 21:02 Uh but that's, that's probably the best way to incorporate it if you're averse to it. Uh some people just like, you know, they soak it in some cream and, and then grill it with some onions. Some, you know, there's a lot of people I like it just like that. Another way to get it in, if you're really averse to the taste is to do, you basically cut it into little cubes and then you freeze it and then you just pop them, like swallow them like a multivitamin. And that's a way to get past the taste if you're really averse.

Allan: 21:36 Cool. Cool. I like that. So we don't necessarily need vitamins and veggies for our vitamins or minerals. We can get all that we need from a mixture of beef liver and some other meats. We can kind of put that together to build out the nutrition that we need. But as far as fiber, because you know, we're told we're going to struggle if we don't get fiber in our diet, our guts gonna hate us. Um we're never going to poop again. Explain a little bit about that. Cause I do see some posts like I just started this carnivore diet and I, you know, I'm struggling. I haven't pooped in three days. I'm like,

Craig: 22:12 Well we see it go both ways. Sometimes people will get a little constipated, some people will get diarrhea. A lot of that just transitioning, you know the body has to adapt and adjust to any big change in your diet. And that's what we talked in the book. One thing that can really help is adding digestive enzymes after your meal and a little HCL hydrochloric acid with your first bites of food and do that in the first few days or a week just to help your body adjust to eating more meat. And that usually helps with any diarrhea issues or digestive issues. But back to the fiber thing, you know, that's a common myth that you need this thing. Your body cannot digest, fiber to bulk up your stills and shove it through the GI track. And to me that just seems weird. You know, first of all, there's studies that have shown, there was a study in Japan that showed that the lower the fiber when you lowered fiber, it actually made constipation better. And there are another study that showed that symptoms of diverticulitis, they had less issues with the less fiber they ate. Zero fiber was the best scenario with almost all their symptoms going away. So having this fiber can actually bulk up the stools and elongate the intestines and irritate them so it's actually can be a negative in that way. And another example is when people say you get, you got to have fiber to go number two, well I always ask them, you know, does a baby that's being breastfed typically have any issue going Number two, I mean know they have no issues with zero fiber in there from the breast milk.

Allan: 23:58 So, you know, I think back to a cat, you know, cat as a pure carnivore and sadly enough, some people try to turn their cats into vegans and that doesn't work out very well. But so you end up with this carnivore and I, I've watched it. A cat will go out in the yard and we'll start eating some grass and it typically just eats that grass at moments where it is already having digestive issues. So is there a case for some fiber in our diet or not really?

Craig: 24:28 Well I don't know if that's, you know, like our dog would do that and would he would gag and throw up. It's like he's trying to purge himself when he would eat the grass. So I'm not sure if there's a connection.

Allan: 24:41 I just figured there was a nutrition, I mean not a nutrition problem, but maybe I digest an issue that the animal is dealing with. It's, it's trying to put something in a system that isn't really in its, in its opinion food.

Craig: 24:53 Yeah. Our, our dog always threw up after he ate the grass. So I dunno if that's why he was doing it.

Allan: 24:58 Now if someone's coming directly from the standard American diet and going into carnivore this is a fairly drastic move. Someone going from keto to carnival or it's actually seems to be a pretty natural transition. I think the core for both is just there isn't additional requirement for electrolytes.

Craig: 25:21 Well, at least a focus on it. You know, I think it's much less of an issue if you're coming from keto, depending on your level of keto to carnivore. Um you're already focusing on electrolytes and making sure you're getting them. So it's probably not as big of an issue there, but it's still important. As important as it is with Kito. You know, carbohydrates are water retaining. So when you eat, the more carbohydrates you eat, the more water you retain. And then when you eliminate the carbohydrates your body flushes out this retained water, which is a good thing. You don't want to be retaining water and bloated. And but what that water go electrolytes that are associated with it. So you need to replenish your electrolytes. And especially when you're eating a whole foods keto or carnivore type of diet because you're not getting sodium in the food where, you know, standard American diet, there's sodium in everything. You know, a milkshake at McDonald's has more sodium than their French fries. So you're getting all this sodium that you don't even realize. And when you go to whole foods, there's no sodium. So you gotta make sure to add that salt back in.

Allan: 26:36 Yeah, I run, I run low on potassium and sodium already. So it is something as I'm, if I'm going to experiment with something that it is something that I, I would definitely make sure that I was getting my electrolytes.

Craig: 26:47 The body, it likes sodium and potassium to be kind of in balance and while eating carnivore, you know, beef and proteins are pretty high in potassium. But what the body has this pathway of, you know, if you're not getting enough sodium it will leach potassium until they're kind of unbalanced again. And so having sodium low can actually result in having potassium loss. So you gotta keep your sodium intake up to keep them balanced.

Allan: 27:16 Yeah. Craig, I define wellness as being the healthiest, fittest and happiest you can be. What are three strategies or tactics to get and stay well?

Craig: 27:28 Well number one I think is just to stay as active as you can. And I think a component of that is getting outside, you know, today we spend so much time in unnatural environments with, you know, artificial lighting indoors, never contacting with nature or the sun or out, outdoors. And I think that's detrimental to health and just mental health as well. But disconnecting and getting out in nature and getting outside I think is a huge component. And just I liked, we were in low carb universe in Spain and one of the speakers was a dentist from the United Kingdom and he said, you should eat like you're never able to brush your teeth again. And I thought that was a pretty interesting take on it and that, you know, anything that is going to mess up your teeth, it's probably messing up your digestive tract as well. And you know, if you, if you just focus on eating the healthiest for your teeth and your body, you're going to end up in a better situation.

Allan: 28:39 Okay. wonderful. Now Craig, if someone wanted to learn more about you, Maria and the book and all the wonderful things that you're doing, where would you like for me to send them?

Craig: 28:50 Well, we have a couple places they can go. They can go to our blog, which is all free recipes and free information that's at Mariamindbodyhealth.com. And then we have a support website for our subscribers with lots of eBooks and things that are available to purchase. And that's keto-adapted.com. And then you can usually find us on social media under Maria Emmerich or Craig Emmerich. And then on Facebook we also have a couple of groups, one called keto, one called keto carnivore and another called 30 day ketogenic cleanse for our cleanse book.

Allan: 29:26 Cool. Well this is episode 415, so you can go to 40plusfitnesspodcast.com/415 and you'll find all the show notes and those links there. Craig, thank you so much for being part of 40 plus fitness podcasts again.

Allan: 29:41 Thank you Allan.

Speaker 4: 29:47 [Inaudible].

Allan: 29:47 Did you know that we have a 40+ Fitness podcast group on Facebook? Yep. We sure do. You can get a 40plusfitnesspodcast.com/group . That's a great place to interact with me and other listeners of the show. I'm on there all the time trying to put out great content, trying to make it fun. It's a really cool place. We have weekly challenges. Go to 40plusfitnesspodcast.com/group and request to join the 40+ Fitness podcast group

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