How is functional medicine different from traditional healthcare? Functional medicine focuses on patient-facing time and individual biomarkers for forming a comprehensive, individualized plan to empower people in matters of their health and well-being. The Western medicine model often leaves much to be desired when it comes to building a long-term relationship with a patient that helps foster their ultimate health. Listen as Dr. Anjali Dsouza and Mike Haney discuss how functional medicine—with a focus on nutrition and metabolic health—helps address mechanisms and root causes, and why this is especially important for women.
- District Center for Integrative Medicine: https://dcimedicine.com
- Connect with Dr. Anjali Dsouza’s on Instagram: https://instagram.com/anjalidsouzamd
- Brain Energy by Christopher Palmer, MD: https://chrispalmermd.com
- Dhru Purohit Podcast: https://podcasts.apple.com/us/podcast/dhru-purohit-podcast/id1381257272
- If you are interested in Dr. Dsouza’s Your Goddess Health Unleashed network, email her at [email protected]
7:30 — Addressing underlying mechanisms of conditions empowers patients
We need to understand the underlying mechanism of a symptom or condition and address that, rather than simply treating the symptom. It was being sick herself that helped Dr. Dsouza recognize that addressing mechanisms is what can make functional medicine empowering.
This kind of root cause—like what’s the driver of an illness?—only became known to me once I became sick and I had to fix myself. And then it was like, I can’t just “green medicine” this. I can’t just give myself healthy foods. There’s something more. There’s a mechanism that I need to understand to be able to fix myself. And then it was like, “Wow—this is all of medicine.” If we’re thinking about upstream mechanisms, we can really stop just trying to fix the dam and just keep symptoms away and we can really help people be healthy.
8:50 — The traditional Western medical system is built on billing codes, which isn’t optimal for patients
Healthcare revenue relies on billing codes, which requires every diagnosis, procedure, and test to be documented and coded for insurance billing and provider reimbursement. But as Dr. Dsouza notes, that process doesn’t always lend itself to building a relationship with a patient that helps foster their ultimate health.
The algorithm becomes, Here’s a symptom or here’s a pathology, here’s the intervention, right? Whether that’s an antibiotic or an opiate or whatever it may be. And then you have pharmaceutical industry that has lots of lobby and lots of money. And I’m not against pharmaceuticals. I think that they can be very useful, but they start to then influence what is taught in medicine—how we think about the care of people. And then there’s just dogma, right? It’s like we just keep learning the same things. We have our blinders on. We do help people. It’s not like there are zero good things coming out of medicine, but it’s hard to expand the worldview, especially because so much of this stuff that we’re talking about here has nothing to do with my prescription pad, right? It has everything to do with my relationship with you as a patient. It has to do with my nutritional counseling, my support of you creating the most beautiful and supportive lifestyle for yourself. There’s no ICD-9 code for that. There’s no billing for that.
13:45 — Functional medicine, by it’s true nature, is rooted in science
Functional medicine uses an individual’s biomarkers to determine and then address—with a comprehensive plan—where necessary any underlying mechanisms and root causes of symptoms and conditions; it does not tout universal, fake cure-alls. But Dr. Dsouza acknowledged that pseudoscience remedies do exist, and that’s not what true functional medicine is.
What’s beautiful about functional medicine is it’s all biochemistry when you go back to it. We’re not grabbing things out of the ground and throwing them at people and doing dances around them. This is all biochemistry, and it comes back to science 100%. And I think once they realize that’s I think they’re very calmed. But the truth is there is a lot of soft science stuff that’s happening and there is a lot of maybe alternative stuff that is out there that may not be optimal for everyone. And I think it can sometimes give this approach a little bit of a bad name because it’s all lumped in the same box.
15:55 — Functional medicine often focuses on nutrition, which can be difficult to study
Traditional medicine approaches focus on results from large randomized clinical trials. But nutrition can be complicated to study on that model because—in most cases—research relies on self-reported survey data. Another concern is that researchers often have difficulty securing funding for nutrition-based research. Or the food industry funds the research, which raises concerns about conflicts of interest. Nutritional approaches in functional medicine are highly individualized, while leaning on evidence-based research.
We just allow ourselves to use our knowledge and use the data of biomarkers that each individual is giving us to make a comprehensive, individualized treatment plan for that person. It’s just a slightly different way of practicing medicine than we are used to, which is: Let’s have these huge clinical trials, and once we have 40,000 people that have shown us X, then we can decide very confidently that we’re going to do this intervention with them. I think that’s more important when you’re talking about a pharmaceutical that has potentially major risk factors and side effects. But when you’re talking about adjusting lifestyle, nutrition, targeted supplements, the downsides are pretty limited. It’s hard to get a lot of these clinical trials done because of complexity.
21:20 — How do we fix a broken healthcare system?
Dr. Dsouza realized in medical school that the Western medical system’s trend of staunching symptoms with medications but not addressing root causes and the lack of time doctors have with each patient wasn’t helping people get well. Her suggestions to fix the broken system are to find ways for doctors to spend more time with their patients and for medical students to learn about nutrition.
This is like pie-in-the-sky dream stuff, right? Right now, I think most of us that are practicing this way have moved out of the regular model. For example, my intake with a patient is 90 minutes long. There’s no way you can do that in a regular clinic. You’re lucky if you get 7 to 15 minutes with your doctor. So I think part of it is that we move our reimbursement for doctors to be more time-based than it is about: How many diagnoses, how many pharmaceuticals did you offer, how many interventions did you provide? We move away from that as the billing model to a time-based model and we try to integrate—and this is happening—more and more of this nutritional lifestyle teaching into medical schools because most physicians are panicked to talk about food, right? They don’t actually know. I think if those two things happen, we can make a difference.
32:33 — Normal ranges aren’t necessarily always optimal
When looking at test results, we have ranges for what’s considered within “normal.” But a person can be close to the edge of a range, and that’s not necessarily an optimal number, or what will leave them feeling their best.
If we talk about insulin as an example, the reference range is from 2 to 19, and most of the patients that come to see me have already been to their regular primary care doctor. And let’s say they’re sitting at like 12 or 15. There’s a chance no one has ever said anything to them about that because it’s not outside of the reference range. I like fasting insulin to be below 5, ideally and optimally between 2 and 3. So it’s also educating people about knowing the difference between what’s in the reference range and what’s really optimal for your most vital health. There’s a little bit of a difference there.
38:12 — What to do when your biomarkers are out of range
The human body is complex, and every person is different. The beauty of testing biomarkers is not to determine a pass or fail, but to help assess what might be causing symptoms or conditions and how to address them.
I really have to set the stage: “You are a perfect, healthy, strong individual, and I am just trying to make you even better and have the best longevity that you could possibly have. And so please know when I am telling you this, it doesn’t mean you’re broken.” I literally have to say that sometimes. I’ve learned from a gut sense who’s going to be more sensitive to that. But it makes sense. When you’ve just tested 60 biomarkers and you’re like, “30 of these are not where I want them to be,” that doesn’t really sound very good. And even though for me, I feel excited because this means we have so much that we can do to make you feel better, from the person listening, it doesn’t always sound like that.
40:50 — Group support can help implement lifestyle changes
Dr. Dsouza also runs a private network, Your Goddess Health Unleashed, for women interested in coming together and learning about maximizing their health outcomes. She says group health can foster camaraderie and accountability and effect more change than when someone is facing their health journey solo.
There’s something about talking about it in the group—and then the women would exchange recipes. And then I’ll be like, “Okay, well tell me how that tastes?” And next week we can talk about, “What did you add to it?” There was the accountability piece. I think there was the normalization of how difficult it is to make changes around food. I mean, on some level you and I were talking about this like, “Gosh, duh, this is so simple. We should just be changing people’s food.” But it’s the most difficult thing that we do. It’s much harder than taking a pill. So I think just having the exchange of ideas, the support of like, “Wow, you did that. I’m going to do that too.” It’s one thing to hear your doctor tell you to do something, and it’s another thing to see someone who is exactly where you are, that comes back and is like, “I made that recipe and it was really good, and when I ate it, I had no brain fog and I felt really energized all day.”
45:30 — Women’s health still lacks research
In the United States, women were largely excluded from clinical trials until the 1990s. This has left women’s health well behind that of men’s.
This all starts with the problem that women are not really in a lot of clinical trials because we’re so complicated. We have menstrual cycles, and we’re not stable biological specimens to study. So that poses a challenge in and of itself because many of the paradigms by which we think about women are just through the lens of what we know about men, and obviously we’re different. So that as an overarching theme I think is important. And then I would say there’s just so much in the fatigue and hormone category that mostly gets dismissed as mental health issues in women that I find really enraging. And sometimes it is mental health and there can be overlaps of many of these things. But we’re not really thinking about how delicate the female hormone system is and that it needs to be nurtured, and nutrients are really important.
47:33 — The importance of women’s health and metabolic health
Metabolic health and female sex hormones have a bidirectional relationship. More research is needed to fully understand all the mechanisms to help women with menopause symptoms, infertility, and other conditions related to the menstrual cycle.
I know many women who have come to me after going to their providers, talking about changes in perimenopause and basically just being told time and time again, “This is just life. Suck it up and deal with it.” I find that heartbreaking. One of my main messages is that it doesn’t have to be like that. There is so much you can do to feel well. And then my last connection point in this is metabolic health is connected to all of that. Your menstrual health, perimenopause, menopause, your cognitive function, fertility—like we are not focusing enough on that as a concept to help women thrive. And we use most of the medical services. We have lots of needs around these common issues, around our hormones and our weight and perimenopause and brain function and mental health. And if someone was talking to all of those women, even if nothing else, just about their metabolic health, I would venture to guess that more than 50% of their complaints would just totally away.
Dr. Anjali Dsouza (00:06):
Most physicians are panicked to talk about food, right? They don’t actually know. Then pie in the sky stuff is like we start educating our children that there’s a much bigger movement around we don’t have to spend doctor time doing so much of this. It’s like more like every kid understands these are some of the basic principles of healthy living so that they’re not so lost when they go off to college and suddenly are living on their own. And no one’s ever talked to them about this. I mean, I wish I had a magic wand honestly, because that’s what it feels like it needs, but.
Ben Grynol (00:45):
I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health and along the way we have conversations with thought leaders about research backed information so you can take your health into your own hands. This is a whole new level.
Mike Haney (01:15):
I’m Mike Haney, Editorial Director at Levels, and today I had a chance to talk to Dr. Anjali Dsouza. I was excited to talk to Dr. Dsouza who’s an integrative and functional medicine doctor that specifically works with women and in the field of women’s health. She runs a practice in DC called the District Center for Integrative Medicine. And that’s really where our conversation focused, on the notion of more integrative approach to healthcare and on functional medicine, what it brings over traditional medicine, some of the problems it can solve, but also some of the challenges that we have around functional medicine, particularly in scaling it and getting that approach to people who need it within the current infrastructure that we have for healthcare here.
I got to know Dr. Dsouza when she led Women’s Health Group around metabolic health. A bunch of her patients used Levels at the same time and in a group setting to help kind of support each other and work with Dr. Dsouza. And we did a round table with those folks and did a blog article about it. And it was really interesting and her learnings around group support for something like tackling metabolic health and paying attention to your blood sugar and using devices like CGMs was really illustrative to us and to her as well. And we talked about that a little bit in this conversation. This is a really fun, wide ranging chat about functional medicine, integrative approach to health, metabolic health and women’s health specifically, and this is where we kick things off.
Where I’d love to start is just to maybe go back a little bit and hear about your journey into medicine. What got you into wanting to be a doctor?
Dr. Anjali Dsouza (02:54):
Yeah, I would love to share. I mean, I have shared with other people in the past. One thing that I feel really grateful for in my story is I grew up in a family context where, I mean, objectively my parents would be called hippies. They were super into nutrition. We were going to the health food stores before there was a Whole Foods, meditation was part of our lives. I wanted to go to medical school expressly for this idea that I was going to be a more holistic doctor. I was going to talk to people about nutrition. I ended up studying nutrition in undergrad and that was my vision. I was seven and I knew this is what I wanted to do and I got to medical school and I was slightly surprised that no one was talking to me about nutrition or lifestyle or the impact of meditation or mindset on our health outcomes, that everything was pharmaceutical driven and/or surgical.
And sadly in my rotations in residency and as I was in medical school, I mean, we’ve heard this story probably from many people. I just kept feeling like people keep coming back, they’re not actually getting better. We give them another medication or another intervention or a consultation with the surgeon and yet they’re still really struggling with their health and there’s not enough time to talk about these other things that really matter. Fast forward to, I have the birth of my first child and I basically fall off a cliff, Mike.
I’m studying integrative medicine, I’m preaching holistic care, I’m talking about nutrition this whole time in my career. But it wasn’t until I had my child and I was sick for the first time that I was like, “Whoa, this system is really broken” because I actually know a couple of things and here I am as a patient and I could not believe how broken the system was. And it was then that I really switched fully into doing this more integrated care, into changing my medical practice model to be able to include and have the time for nutrition, lifestyle counseling and really helping people have health vitality and not just fix a diagnosis, which is a very different thing.
Mike Haney (05:11):
Oh, there’s so much there I want to unpack. My follow-up question that was going to be about your journey into the integrative side or the functional side because so many physicians that we talk to that are in this sort of functional or integrative world have some kind of a conversion experience where they’re going through doing a traditional path and slowly kind of come to this realization of this isn’t working and discover functional med. I’ve never talked to somebody who came into med school with that point of view. What was that like as you got to med school, as you started going through the motions, having already come in with this sort of idea of functional or integrative care in some of these alternative “theories?” What were you thinking as you were going through the traditional curriculum that’s not emphasizing this? Were you thinking, “Oh, I must be wrong, this is the way we’re supposed to do it?” Or the whole time were you sort of banging on people’s doors going, “Hey, what about? Why aren’t we talking about?”
Dr. Anjali Dsouza (06:09):
It was the latter for sure. I definitely, I mean fortunately maybe I was really hell bent that I was right about this. We still needed to find a way to talk about this. And I just was like, I mean, I would email professors of medicine at random medical schools all over the country to just be, “Talk to me. You’re doing X with this kind of food thing. Will you talk to me on the phone?” I was just beating down the door of everyone. Unfortunately I didn’t find any local mentors for myself, but I kept seeking out more and more education. I went to naturopathic school for a little bit, even during my allopathic medical journey to just be exposed to herbal medicine and acupuncture and to just broaden my horizon on what are all the things that are available to help people feel well.
I stayed in that just active learning phase. But here’s the thing that I think maybe is the nuance because you were kind of saying many people have an aha moment and they switch. And really, I was kind of in this game from the beginning, but the difference is I think I was thinking about holistic care and maybe alternative options for people and that was very much part of my worldview. But this kind of root cause, like what’s the driver of an illness, only became known to me once I became sick and I had to fix myself. Then it was like I can’t just green medicine this, I can’t just give myself healthy foods. There’s something more, there’s a mechanism that I need to understand to be able to fix myself. Then it was the like, “Wow, this is all of medicine. If we’re thinking about upstream mechanisms, we can really stop just trying to fix the dam and just keep symptoms away and we can really help people be healthy.”
Mike Haney (08:06):
Well, this is an enormous question, but I always like to hear people’s perspective on it. Why is medical training and I guess by extension, the medical system the way it is? Why is this root because approach so anomalous within both our training and our practice of medicine?
Dr. Anjali Dsouza (08:23):
Yeah. I mean, think because some of the foundations for a more evolved medical system, because at some point way back when we were just throwing things at people and hoping it would work and then we became a little bit more science oriented. And this is in the time when we’re kind of identifying microorganisms and we’re really getting into antibiotic therapy and the mindset or the thinking, the brain, the algorithm becomes like here’s a symptom or here’s a pathology, here’s the intervention, whether that’s an antibiotic or an opiate or whatever it may be. Then you have pharmaceutical industry that has lots of lobby and lots of money, and I’m not against pharmaceuticals. I think that they can be very useful, but they start to then influence what is taught in medicine, how we think about the care of people. Then there’s just dogma, right?
It’s like we keep learning the same things. We have our blinders on and we do help people still, it’s not like there are zero good things coming out of medicine, but it’s hard to expand the worldview, especially because so much of this stuff that we’re talking about here has nothing to do with my prescription pad. It has everything to do with my relationship with you as a patient. It has to do with my nutritional counseling, my support, I view creating the most beautiful and supportive lifestyle for yourself. There’s no ICD-9 code for that. There’s no billing for that. I mean, I do think this is very slowly changing, but those are my kind of thoughts about why that system is so ingrained.
Mike Haney (10:04):
It’s an interesting point of how much of it is inertia from a time when that interventional approach made sense because it was so revolutionary. And that’s where you were seeing these unbelievable gains, right? Everybody was dying of cholera and then we figured out how to stop people from dying of cholera. We should just do that before we think about their diet.
Dr. Anjali Dsouza (10:24):
Mike Haney (10:24):
Which we didn’t have as many levers at the time, but I also take your point that the medicine is helping people. I feel like this is one of the disconnects is that whenever you hear these stats about how we don’t have the greatest medical outcomes in the world, I think people are often surprised because they think, well, we’re the most technologically advanced, but the negative effects of the way that we practice medicine seem kind of pernicious and hidden, right? It seems like it’s hard to recognize what the potential benefits of a shift would be given that inertia, given the infrastructure, given all of the changes that would have to be made to shift to a different kind of approach.
Dr. Anjali Dsouza (11:06):
There’s so much momentum in that. It’s so difficult to move out of that. I think that’s exactly right. But you start to have these little stories, whether it’s physicians reaching their burnout level of I’m not really helping people, this system is broken and slowly leaving. I mean, the Institute for Traditional Medicine, which is one of the places where I trained, it used to be that it would be maybe a hundred people in a conference. And now these conferences sell out with thousands and thousands of people coming to learn this way to really care for people, which I take as really positive that there’s some momentum that’s starting to build around changing this narrative basically.
Mike Haney (11:46):
When you talk to colleagues in the medical profession who are not further along in that journey yet, what do you hear? I take your point that it’s starting to change and there is starting to be a build of more folks in those conferences, more interest in this. The fact that there is a functional medicine institute at Cleveland Clinic has always to me seemed like a legitimizer of this approach. But as you say, it’s not the vast majority of the field. What kinds of things do you hear? What does the general medical profession’s take on this approach? Are you guys quacks or do they all sort of go, “Yeah, I’d love to do that if I could figure out how to make it work?”
Dr. Anjali Dsouza (12:23):
Yeah, it’s a great question and I think that there’s a little bit, my initial experience with another physician who knows nothing about this is really skepticism and a little bit of an eyebrow of, “Okay, whatever you say.” But I think the outcomes really speak for themselves. I remember when I first started practicing and I would try to introduce myself to other colleagues that I might refer to. No one was rude, but they certainly weren’t like, “Oh yeah, give me your card, I want to refer to you. This makes a lot of sense.” But over time, as I’ve been practicing, as I said, the outcomes speak for themselves, people get better. And now I have clinicians, physicians calling me wanting to refer to me and maybe even tell me a little bit about where did you learn this or what is functional medicine exactly, or how do you find the time to talk to people about the nutrition piece?
There’s a little bit of curiosity that shifted. Now there are some super old school, very classically academically trained physicians who I think are lovely, that maybe are a little bit more concerned about adopting this full sale. Maybe still think there’s a little bit of pseudoscience in this, but when we can explain, and I think part of what’s beautiful about functional medicine is it’s all biochemistry when you go back to it, right? We’re not grabbing things out of the ground and throwing them at people and doing dances around them. This is all biochemistry and it comes back to science 100%. And I think once they realize that, I think they’re very calmed. But the truth is there is a lot of kind of soft science stuff that’s happening. There is a lot of maybe alternative stuff that is out there that may not be optimal for everyone. And I think it can sometimes give this approach a little bit of a bad name because it’s all lumped in the same box, right?
Mike Haney (14:24):
Yeah. I’m glad you went there. That was going to be the next question I wanted to ask is to sort of flip this from the other perspective and ask what you think the maybe blind spots, or maybe to phrase it more generously, the areas of the functional approach that need more research, that need more validation. What kinds of things do we not know that we wish we knew to either be more effective in this treatment or to make this approach to medicine more palatable to the mainstream? Whether that’s insurers or whether that’s the rest of the medical industry.
Dr. Anjali Dsouza (14:58):
I mean, I think the challenges, so much of this approach is really founded on nutrition and on food. And this is just inherently difficult to study. We can do kind of population studies and we can make correlations, but there are so many things that make it difficult to study nutrition on a mass level. And I guess this is part of where you have to almost make a shift. Part of the functional medicine approach is very individualized. I may know that the Mediterranean diet is a really good intervention that has lots of data behind it to support it, but I may recommend for the person in front of me based on their markers and what their goals are, a ketogenic diet because that’s what’s actually going to help them thrive. It’s partially we can always be building our repertoire of kind of evidence-based. But I also think it’s about shifting around things that are not going to have major medical consequences.
We just allow ourselves to use our knowledge and use the data of biomarkers that each individual is giving us to make a comprehensive individualized treatment plan for that person. It’s just a slightly different way of practicing medicine than we are used to, which is like let’s have these huge clinical trials and once we have 40,000 people that have shown us X, then we can decide very confidently that we’re going to do this intervention with them. I think that’s more important when you’re talking about a pharmaceutical that has potentially major risk factors and side effects. But when you’re talking about adjusting lifestyle nutrition, targeted supplements, the downsides are pretty limited. It’s hard to get a lot of these clinical trials done because of complexity. And also just like who’s funding these trials around food and lifestyle? Nobody really gains from those. There’s not a lot of money for it, right?
Mike Haney (16:54):
Right. Or it’s the food industry funding them. That’s such an interesting point about futility is too strong a word, but about the challenges of doing a massive RCT around some of these nutritional things. I run into this all the time when we’re trying to review research for the content we’re creating that. We did a big article on eggs. Sam, our CEO, sent me a note and was like, “Can we just do a thing on whether or not eggs are good for you?” I was like, “Sure, we’ll tackle that. Let’s see what the literature says.” And it’s all over the board. And of course it’s all over the board because how do you effectively do an RCT around a particular food?
Everything is survey data and you get these seemingly impressive participant counts. It’ll be like, “Oh, we looked at data from 500,000 people in three countries.” And you’re like, “Well, that’s got to be great,” but it’s survey data and it’s like, “Well, this many people ate this many eggs and they saw this, but then this other survey says that.” But it’s an interesting distinction that compared to something like a pharmaceutical or a vaccine where we can do much clearer randomization and control, we’re just not going to get that kind of data out of nutritional interventions.
Dr. Anjali Dsouza (18:02):
No, I don’t think that will ever happen. And again, it’s that what is the risk of harm? And the risk of harm around potentially a vaccine or a pharmaceutical intervention is much higher. The rigor and the standard that I have for that is going to be much tighter than it is for me to say, “Let me work with someone, try an intervention around food, see how they respond, check their biomarkers.” The chance that I’m going to do harm is literally almost zero, right?
Mike Haney (18:30):
Then it makes me wonder what is the research scaffolding then that we need to put in place around this other kind of approach? If we’ve come from a world in which that idea of a random control trial is our sort of gold standard, that’s our base of how we know whether or not X treatment is going to work. Then we combine it with all of the lab work and the cell lines and the in vitro stuff, and we could say, “Okay, we’ve got the physiology side, we can explain the cell biology or the biochemistry. It’s happening. Then we’ve got the real world random control trial that shows X is working. Great, let’s run forward.”
It feels like this approach is just going to need a different set of research to underpin it beyond the is something that would back up or give more guidance to the highly individualized approach. It’s always going to be individualized, but obviously you can’t start every treatment plan with every individual going like, “All right, we’re starting from scratch because you’re an individual.” What do you think about as the types of research or studies that we need to help build a better library around what works in this more functional approach?
Dr. Anjali Dsouza (19:39):
Yeah. I mean, I think if we can start thinking about condition specific interventions, if you think about autoimmunity and you think about the elimination approach of taking out certain foods that are going to be inflammatory and you collect data for clinicians and their patients over time and it may not be an RCT type of intervention, but you start to collect enough data to say, “Wow, this really does work.” I think condition specific food interventions make sense. I also think that we can lean towards some of our evidence-based knowledge of, okay, we’re not going to ever put someone on a bacon diet for example. There are some things that we can pull from nutritional research that give us conceptually where we want to go or not.
Then when you’re thinking about this approach, I kind of think it’s like, okay, there’s some evidence base you pull, there’s some experience of the clinician working with different conditions and understanding over time what works and it doesn’t. That’s kind of just the experience, institutional knowledge of practicing medicine. Then there’s the piece of integrating the person in front of you. This is whether it’s the patient preference or whatever their biochemical needs are, it’s a different framework, Mike. It’s a totally different way of thinking about caring for patients.
Mike Haney (21:04):
How do you see that scaling? This feels to me always where we run into the brick wall of changing how we practice healthcare in the western world to this model is right, how do we do it for tens of millions of people?
Dr. Anjali Dsouza (21:18):
I know. Well, I mean, this is pie in the sky dream stuff, right? Right now, I think most of us that are practicing this way have moved out of the regular model. And for example, my intake with a patient is 90 minutes long. There’s no way you can do that in a regular clinic. You’re lucky if you get seven to 15 minutes with your doctor. I think part of it is that we move our kind of reimbursement for doctors to be more time-based than it is about how many diagnoses, how many pharmaceuticals did you offer, how many interventions did you provide? We move away from that as the billing model to a time-based model. And we try to integrate, and this is happening, we try to integrate more and more of this nutritional lifestyle teaching into medical schools because most physicians are panicked to talk about food.
They don’t actually know. I think if those two things happen, we can make a difference. Then pie in the sky stuff is like we start educating our children that there’s a much bigger movement around you don’t have to spend doctor time doing so much of this. It’s more every kid understands these are some of the basic principles of healthy living so that they’re not so lost when they go off to college and suddenly are living on their own and no one’s ever talked to them about this. Those would be some of my thoughts. I mean, I wish I had a magic wand honestly, because that’s what it feels like it needs, but.
Mike Haney (22:57):
All of that actually sounds very practical though. And I do want to talk about technology and its role, but often the answer I’ll get is technology, like AI will save us or we’ll just do more of this with big data. Whereas I feel like what the things you just described in terms of changing incentives and billing structure is not going to get everybody to a 90 minute intake, but if it gets you to a 30 versus a five, that’s definitely getting better. The point about educating the children makes a lot of sense because it feels like that’s … To me it feels like we are inevitably headed towards a shift over the next decades to a more preventative care model because there’s sort of no alternative. It’s just becoming increasingly clear that what we’re doing doesn’t work for anybody. It’s not working for patients, it’s not working for doctors, it’s not working for the medical system.
And it does feel like maybe it’s just because I live in this world now, but that we’re at the very front of that kind of change. And that’s what, to me educating kids about is changing that mindset to no, the point is live healthy and then if something ultimately happens, which it probably will because we’re humans, but it’s not about do whatever you want, live in this very challenging world of processed food and whatever, and then when you ultimately get sick, now we just need an intervention and a fix. Shifting away from that just feels like it has to be inevitable.
Dr. Anjali Dsouza (24:22):
No, I really hope so. Yes.
Mike Haney (24:26):
What do you think about the role of technology in this shift?
Dr. Anjali Dsouza (24:29):
Yeah, it’s tricky. I mean, I think for me, I really believe from a personal perspective, and there’s lots of literature to support this, that the biggest part of the therapeutic dynamic is the relationship between me and the person in front of me. If I am even just a switch to us typing away on our computers and entering all the things that you tell me and not looking at you and seeing you and being with you fully, that already has a negative impact. If we switch all the way to AI, I mean, sure there may be some efficiency we gain, but just the way social media seemed amazing and now we’re like, “Oh my gosh, what is it doing to the mental health of all of our adolescents?” There will be downsize.
And I think that that therapeutic alliance will absolutely, the power of it, whether you want to call that a placebo effect or not, but the power of that therapeutic dynamic will vanish if we push too much in the technology direction. That relationship is sacred that you have with your clinician. I’m fearful of it. And yet I also recognize it’s a necessary evil. This is just the world that we live in.
Mike Haney (25:41):
How do you think about technology from the perspective of data, of biodata? Obviously we know each other through CGMs and putting those on folks who don’t have a clinical diagnosis. And that’s a lot of our argument around it is it’s better for people to have a picture into what’s going on inside their body and we just need a lot more of that data. How do you think about the future of that? What would you like to see there and what role does that play in how you treat patients?
Dr. Anjali Dsouza (26:08):
That I feel differently about. I think that the sitting in front of your computer or literally one day a robot interacting with someone, that I feel like I have some nervousness about it, but the utilization of biological tracking to provide the doctor with an insight into what’s going on with your body and to literally give back power to the patient even to be like, “Okay, this is what’s going on,” I think that that’s amazing and I hope that there’s more of that. I hope that we have continuous cortisol monitors at some point and then its dark side obviously as we can get into this overly neurotic place as humans with all the tracking we do. You have to also know who you are. If you’re someone that’s going to do all the tracking and then it’s going to create an anxiety disorder in you because you’re like, “Oh my gosh, all this stuff is broken,” then that’s where the dark side is. But me personally, I love tracking and I love getting that information from patients. I think it’s really powerful and it gives me so much information so quickly.
Mike Haney (27:14):
You mentioned cortisol. What else would you like to see realtime continuous tracking of?
Dr. Anjali Dsouza (27:20):
Yeah. I mean, I do women’s health, so it would be fascinating to see sex hormone fluctuation throughout days or weeks or months in a menstrual cycle. I mean, I think that that would be amazing when I’m trying to support women in their menstrual health and through perimenopause and menopause. That would be super cool.
Mike Haney (27:41):
What about other kinds of functional interventions? What else do you think is out there on the technology front that you hope is coming or that’s kind of right on the edge in terms of either technology or other types of treatments?
Dr. Anjali Dsouza (27:57):
Yeah. I mean, I think there are some of these things. Being able to very quickly get a sense of lean body mass versus fat mass in a body without actually having to go do a full DEXA scan. I mean, this is kind of hopeful thinking I guess, but things like that that give you more information on musculoskeletal health quickly I think would be really cool. I also think inflammatory markers, if we had ways to measure cytokines more actively in a real time way, that would be interesting from an infection and inflammation perspective. But I’m not aware of these things coming down the pipeline, Mike. It’s more that it would be really cool if those things did.
Mike Haney (28:40):
Right. Well, shifting to the here and now, I’m curious on that topic of metabolic markers, what do you like to measure? What does a blood panel look like for a patient who’s coming to you?
Dr. Anjali Dsouza (28:52):
Yeah, so typically everyone’s going to get obviously a fasting glucose, a hemoglobin A1C. But I always do a fasting insulin and if I can and if I need to because of what the patient profile might be, I may even do a three hour kind of watch glucose and insulin over time after someone consumes a heavy glucose drink so that I can see not just what glucose is doing, but how is insulin reacting. Because that would be the other awesome thing. We have these CGMs, what if one day we could have a CGM with the insulin read with it? I mean, that would be amazing to see. That would be the other thing that I will sometimes do.
Then on lipids, I will always do a lipid panel. I like to look at the triglyceride to HDL ratio. That’s really important to me. I will also look at sex hormone binding globulin, which is not often used, but can be a marker to assess metabolic health. Anything below 40 on the sex hormone binding globulin, I’m really thinking, “Huh, there may be some metabolic dysfunction here.” Then I will look at your liver enzymes because it can be a sign that there was some fatty liver starting or accumulating. And that can be another sign of metabolic dysfunction. Those are all the classic, no matter what, you’re going to probably get those. Then I do more of the kind of two or three hour testing for somebody that I know is maybe pre-diabetic or has some metabolic dysfunction already defined.
Mike Haney (30:20):
How about things like cortisol or CREP? Are those things you look at frequently?
Dr. Anjali Dsouza (30:24):
Oh, definitely. I thought you were just wanting me to give you my metabolic little panel, but yes, everybody gets a CRP level because I mean, as we know, not just what’s going on metabolically, but how that mixes with inflammation is really going to turn on problems for people. Yes, everybody gets an HSCRP. If we’re talking about my standard blood panel, we also do nutrients. I’m looking typically B12, folate, iron, ferritin. I will look at zinc and copper because those are really important to be in balance. Then obviously a CBC and a CMP for everybody.
Mike Haney (31:02):
And what do you tell folks about, I would imagine for a lot of people coming to you, this is the first time they’re getting this kind of stuff tested and I just worked on a piece recently where the aim of it was to basically tell people how to get more, assuming they’re not going to a functional medicine doctor, because most people don’t and most people can’t afford it because they’re often not covered by insurance, so if you’re going to go to your regular physician, we were getting at what kinds of tests might you ask for? What other kinds of things, or even if you got to go out of pocket and you pay 20 bucks to get insulin from the local lab, what do you tell people about ongoing measurement of some of these things? What’s useful to look at with what kind of frequency?
Dr. Anjali Dsouza (31:41):
Yeah. If I were to test all those markers and they were all normal, I probably wouldn’t test them again for another 12 months in that person. But the ones that are abnormal, let’s say fasting insulin was elevated and fasting glucose was elevated and they were starting to be pre-diabetic, then I’m typically starting a treatment plan and then I actually will test every three to four months. And part of that is I like people to stay in the momentum of seeing the change and getting excited about the change. Saying come back six to nine months from now, I mean, it’s just out of sight, out of mind, right?
If you can, I think doing it every three, four to five months at the most window when you have some numbers that are abnormal. And when I say abnormal, I even mean not optimal, right? Because if we talk about insulin as an example, the reference range is from two to 19. And most of the patients that come to see me have already been to their regular primary care doctor. And let’s say they’re sitting at 12 or 15, there’s a chance no one has ever said anything to them about that because it’s not outside of the reference range. I like fasting insulin to be below five, ideally and optimally between two and three. It’s also educating people about knowing the difference between what’s in the reference range and what’s really optimal for your most vital health. There’s a little bit of a difference there.
Mike Haney (33:11):
Yeah, that feels like another real distinction between traditional practice and functional practice. It’s something I had never really thought about before working here and being exposed to these other ways of thinking of getting a blood panel and looking at optimal versus non-optimal and what does it mean if you’re at the top end of optimal? Recognizing that some things fluctuate and blood panels aren’t always accurate and it’s always worth three testing or looking at correlations. But just being within the range, particularly insulin is such an interesting example because that reference range is so huge.
Dr. Anjali Dsouza (33:39):
It’s enormous. Yeah. But for that matter, it’s also that glucose. I’ve seen people who will come to me and their fasting glucose is at 99. I’m like, “Oh, has anyone talked to you about this?” They’re like, “No, because it’s normal.” And I’m like, “Well, actually,” right? I mean, we could do so much if we were talking to people about their fasting glucose as it was going into the 90s. There’s so much that could be done there. Yeah, there’s a big difference between optimal and normal by reference range.
Mike Haney (34:11):
I wanted to move a little bit into glucose and blood sugar for people who don’t have a diabetes diagnosis yet, but maybe that’s an interesting place to start is if I’m a patient who comes to you and I come back with that fasting glucose of 99, what’s the conversation? What do you talk about?
Dr. Anjali Dsouza (34:26):
Yeah, so I think it depends, and as always it goes back to, well what’s the story of this person? Is this a person who has everything really dialed in nutritionally and I don’t really need to tackle that box, or is it not? Let’s just assume it’s not for the purpose of this conversation. Then we’re going to do a pretty deep dive. I’m going to have them to do either a three or a five day diary, which has its limitations, but it gives me a little window at least into what they’re eating. The first thing we’ll do is figure out what’s pushing this from a nutritional level? Is it that they’re pounding Starbursts all day long? Is it not? Is actually the nutritional part quite good? And it’s really more about they need to pair their foods a little bit better because they’re eating oatmeal and a croissant and I don’t know, having a Diet Coke in the morning and that that’s really driving things?
I try to address is this nutritional? If it’s not nutritional, then we look at the stress and cortisol box and I will test. I will do saliva testing on the adrenals so that I can look at cortisol patterns. And what’s funny here on the east coast is most of the time people tell me that they’re not stressed because I think they’re like we’re all just so used to being stressed that I’m like, “Well, how’s your stress?” It’s like, “It’s fine. I don’t have any stress.” A partner at a law firm has two kids under the age of four, you get the idea, right? Sometimes doing the testing, I don’t think it’s mandatory, but it’s really eye-opening for the patient because when they see their cortisol level is three standard deviations away from the mean, they’re like, “Oh, okay, this is actually, this is a real thing that I need to deal with.”
And it can start a conversation where they feel more invested and trying to move the needle on that. But those are the two big boxes. Then I think about environmental toxins or genetics and how that may play a role. If those other two, if nutrition and adrenals are totally dialed in, then there may be other things, whether it’s toxins or environmental or genetics. Then we might kind of approach this differently. First we’ll think about dialing in nutrition even more because maybe they’re just vulnerable and they need something a little tighter. I have used herbal medicine and I use pharmaceuticals too when I need to if it’s really advanced. Those would be kind of the three areas that I would dig in with someone if I found that there was some metabolic dysfunction present in a laboratory.
Mike Haney (36:57):
What have you learned in working with patients over the number of years you have with this approach, particularly as it relates to things like glucose and insulin or that kind of core metabolic health?
Dr. Anjali Dsouza (37:08):
Well, so much. Let me see what’s most useful. I mean, I think one thing that I have learned is as a clinician is I have to slow down because I get really excited about wanting to do all the things, but most people really need interventions to be small and limited and doable. And it may feel a lot less than what I want to do, but I have learned to scale back significantly on what I ask for someone so that I know when they come back they can report a success to me. And that’s going to be really empowering for the next step to be positive. I think that’s one thing that I’ve learned. I think the other thing that I’ve learned is you have to be careful with when you’re doing this really comprehensive approach, sometimes it can make people inadvertently feel pathologized, right?
Because you’re like, “Oh, look at all of this information I have, and this is a little out of balance and this is not optimal.” I really have to set the stage for you are a perfect, healthy, strong individual and I am just trying to make you even better and have the best longevity that you could possibly have. Please know when I am telling you this, it doesn’t mean you’re broken, right? I literally have to say that sometimes and I’ve learned from a gut sense who’s going to be more sensitive to that. But it makes sense, when you’re giving people, when you’ve just tested 60 biomarkers and you’re like 30 of these are not where I want them to be, that doesn’t really sound very good. And even though for me I feel excited because I’m like this means we have so much that we can do to make you feel better.
From the person listening, it doesn’t always sound like that. I think those are big takeaways that I have learned as a clinician. Then I would say, and this is how our work again dovetails the power of group medical visits and the group and community in affecting change. And I would say specifically around metabolic health is just astronomical, Mike. I mean, you can find this too in the literature, but it is just the most powerful thing that I have seen. It was during the pandemic that just as we knew about the more abysmal outcomes for people that were more metabolically sick with COVID, I just was like I need to do something on a larger scale, and I’m really interested in supporting women, that is going to move the needle for people around this. That’s when I decided to set up these groups.
I’m now on, I think iteration six or seven now, and things that I said so many times one on one that were maybe helpful and maybe there was a little movement that was done there. The change that I would see when doing it in the group context was just mind blowing. It was really incredible. That’s the other thing that I think is really powerful that I’ve taken away that I hope to do more of. I think there’s something, and I do think this goes back to your question about how do we scale this? How do we make functional medicine more available? I think if you’re doing it in a group context, it does become more financially reachable and actually the outcomes are better. It’s a win/win on both sides.
Mike Haney (40:25):
And give me an example of something that really clicked in the group setting that didn’t maybe in an individual one-on-one relationship.
Dr. Anjali Dsouza (40:32):
I think it’s the food stuff specifically. That just becomes so much more engaging. I can say, “Okay, well here’s what I would recommend for breakfast.” The one on one the person would listen to me and be like, “Okay.” Then I would see them again. “How did that go?” “Well, actually I didn’t do it, but I will do it next time,” right? But there’s something about talking about it in the group. Then the women would exchange recipes and then I’ll be like, “Okay, well tell me how that tastes and next week we can talk about what did you add to it?” There was the accountability piece. I think there was the normalization of how difficult it is to make changes around food. I mean, on some level you and I are talking about this, gosh duh, this is so simple. We should just be changing people’s food, but it’s the most difficult thing that we do, right?
It’s much harder than taking a pill. I think just having the exchange of ideas, the support of like, “Wow, you did that. I’m going to do that too.” It’s one thing to hear your doctor tell you to do something and it’s another thing to see someone who is exactly where you are that comes back and is like, “I made that recipe and it was really good and when I ate it, I had no brain fog and I felt really energized all day.” Then someone listening is like, “Oh my gosh, I’m totally going to do that.” There’s just so much more energy around doing the things that are recommended because it’s almost like it’s not coming from me. It’s like it’s coming from their peers.
Mike Haney (42:00):
I think that’s been one of the really valuable learnings for us as our community has grown around Levels. And I know we have [inaudible 00:42:07] on Facebook and we have a team member now who runs community and interacts with our community a lot, is that power, particularly for something like these kinds of changes which are pretty weird for people to put on a CGM to look at something that’s going on in your body continuously to watch these kinds of reactions. How much that just feeling you’re not alone in it is important. I’m curious what you’ve learned having run a number of these groups now about the durability of what people learn. I assume the group sort of comes to an end at some point. What do you know about what happens to the people who are in the group post group?
Dr. Anjali Dsouza (42:39):
Yeah, this is a great question and part of the kind of energy around this or the excitement around this actually prompted me to set up an entire online network for busy women working on their health where we can celebrate their wins, stay in the momentum, be a place for check-in. My sense is that, and I’ll tell you more as I collect more data over time, but I do think that that was an integral piece because the 12 weeks, many people made enormous changes around their weight and they saw huge changes around their CGM data. But then it’s like, “But I’m not ready to just say goodbye. I need a little bit more like touch points.”
I created that network for people to come and now every Monday at 12:00 noon I will come on, whoever’s available will come on, we’ll talk about what’s going on healthwise. And I think that it’s almost like a health coaching situation and I think that that momentum is really what’s allowing people to stay in success because life happens. And when you’re not just solely focused on, “Oh, well I’m doing this 12 week program,” it’s easy for things to slowly dissipate. I think that has been part of why it’s been so successful in the long term is because I have created a longer term touchpoint for people.
Mike Haney (44:00):
I love the connection between that back to the point of scaling, both scaling a functional approach, but also as probably a core part of this paradigm shift in how we do medicine, how we think about health and making it more of a community thing as opposed to, “I got sick, I went to the doctor and maybe I talked to my wife about it” and that’s as far as it goes. Or I’m in CrossFit and that’s my community. But something just broadly about health and nutrition and eating being a natural part of what we talk about with whatever our community might be.
Dr. Anjali Dsouza (44:36):
That’s right. Yeah, I think that’s right. And it’s become this lovely place where people come with all kinds of things. Maybe they’re not even talking about a health goal, but they’re talking about something that’s happening with their kids or their husband. And I think that that kind of connectedness is really, it is part of health outcomes too. That sense of I have people, I am part of something, there was somebody that cares about what’s going on with me. That is part of really improving our health as well. It’s definitely tapping into that also, which is great.
Mike Haney (45:08):
As somebody who focuses on women’s health, what is either mainstream medicine or even maybe mainstream functional medicine still missing about women’s health and particular women’s health and metabolic health? What’s being overlooked? What are we not talking enough about?
Dr. Anjali Dsouza (45:24):
Oh my gosh. How long do you have, Mike? Where do I begin? I mean, I think this all starts with the problem that women are not really in a lot of clinical trials because we’re so complicated. We have menstrual cycles and we’re not stable biological specimens to study. That poses a challenge in and of itself because many of the paradigms by which we think about women are just through the lens of what we know about men. And obviously we’re different. That as an overarching theme I think is important. Then I would say there’s just so much in the fatigue hormone category that mostly gets dismissed as mental health issues in women that I find really enraging. And sometimes it is mental health and there can be overlaps of many of these things, but we’re not really thinking about how delicate the female hormone system is and that it needs to be nurtured and nutrients are really important and we offer birth control like nobody’s business.
And this is fine and I have no issue with it other than it’s actually causing a lot of hormone disruption in women. It’s actually an endocrine disruptor itself. It’s going to because nutrient insufficiencies, women feel worse, and yet we don’t have any answers for them. Then we tell them it’s a mental health issue. That’s one box. I think another box is we are not sufficiently educating and empowering women around the change in perimenopause and menopause. There’s so much negative energy about what happens to a woman as they go to menopause, right? You’re going to be fat and brain foggy and you’re not going to remember anyone’s name and it’s going to be horrible. None of that has to be true. But if we’re not thinking from a kind of biochemistry, preventative lens to support, because things do change, right? In our bodies. Ad if we’re not thinking about how to support that, then yes, some of that will happen.
But I know many women who have come to me after going to their providers talking about changes in perimenopause and basically just being told time and time again, “This is just life, suck it up and deal with it.” And I find that heartbreaking. And one of my main messages is that it doesn’t have to be like that. There is so much you can do to feel well. Then my last kind of connection point in this is metabolic health is connected to all of that. Your menstrual health, perimenopause, menopause, your cognitive function, fertility. We are not focusing enough on that as a concept to help women thrive. And we use most of the medical services. We have lots of needs around these common issues around our hormones and our weight and perimenopause and brain function and mental health. If someone was talking to all of those women, even if nothing else just about their metabolic health, I would venture to guess that more than 50% of their complaints just totally go away.
Mike Haney (48:40):
That’s really, it’s encouraging. That’s great to hear that there’s a lot of blue skies still out there as folks try to focus on just getting people to think more about this as a one vector of their health. I’d love to dive in even more specifically if you don’t mind, and this is totally selfish because I’m working on a piece about this, how do you think about women and fasting? What’s unique about women when it comes to intermittent fasting and maybe a subset of that as women in keto? Or maybe that’s sort of a wholly separate question.
Dr. Anjali Dsouza (49:11):
Yeah, absolutely. I’d love to talk about this. I think fasting can be a great intervention. On a very simplistic level, it’s just taking the food question out for a little bit and can help you rest your digestive system, not have to worry about what you’re eating. There is data as you get into deeper fasting that you’re going to turn over dense cells and it’s good for autophagy and it can be great for improving insulin sensitivity. But I do think fasting in women is nuanced because of our system, especially for menstruating females. What’s happening throughout your cycle is going to determine if fasting is a friend or foe for you. If I am fasting, let’s say in the luteal phase of my cycle, which is where I’m going to be making lots of hormones, my body is kind of thinking that I might be preparing for pregnancy, it’s working really hard and I’m doing deep fasting during that time, I’m doing a 16, 18 hour fast during that time, that’s going to be perceived by my body as a threat, as a stressor, and that’s actually going to create inflammation.
It might actually negatively impact my hormones. I think with fasting in the menstruating female, it’s really about figuring out where to put the fasting so that your hormones are actually pretty baseline stable. This is typically in the first week of your cycle. In the first week, so that’s bleeding and into maybe day seven to nine, there’s not much going on. Estrogen is pretty low, progesterone’s pretty low, testosterone is low, and then it starts to rise towards the end. There’s not much demand hormone wise, and you can do some pretty deep fasting. And I actually think there’s lots of benefits to be done then. The problem is fasting has been like it’s all over the place and we don’t really understand when to be doing it. And I think women can do it and inadvertently feel worse, but also not get the outcomes they want.
Whether that’s energy or improvement in weight or improvement in metabolic health or improvement in menstrual health. It’s really about timing that’s important. And I would say that’s true about the ketogenic diet too. Same idea. This is a pretty kind of severely limited diet from a carbohydrate perspective, which I think can be great. And I use nutritional ketosis all the time in my patients, but it’s not something that a menstruating female should just do without any limits. Just get in there and just do it ad nauseam. I actually think you can end up potentially hurting yourself.
Mike Haney (51:54):
Do you have any books or podcasts that you’d recommend for folks that you found really helpful?
Dr. Anjali Dsouza (52:00):
Yeah, so right now I’m really excited about Chris Palmer’s new book, which he is a psychiatrist at Harvard who essentially is talking about the ways in which metabolic health are so pivotal to mental health. And I so appreciate this dialogue because I think we are in a world where we’ve been taught that neurotransmitters and pharmaceutical medications are really the only way to affect change for mental health. But this is kind of a lovely eye-opening, really game-changing book about the function of the mitochondria and metabolic health specifically in optimizing mental health. That’s definitely a favorite right now and podcast, so I love Dhru Purohit’s podcast. All the people on there I enjoy listening to and I think he’s a great interviewer. Those would be my two top recommendations.
Mike Haney (52:57):
Excellent. And for listeners, Chris Palmer was a guest on this podcast, just a few episodes to go. Go back and listen that on either before or after you read the book. And Dhru is a real friend of the company as well. We love him. Well, thanks so much. This has been fantastic.
Dr. Anjali Dsouza (53:10):
Yeah, I really appreciate your time and thank you guys for all that you do. It’s really like, it’s lovely to have your product, to be able to give with patients and to work within my groups. I’m supremely grateful.